Columijia ^nibergitr
mtfjeCitpofi^EttJliorfe
COLLEGE OF PHYSICIANS
AND SURGEONS
O^^ ^
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Reference Library
Given by
Robert ■ Gr.oj\tnor. •
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[;iANS,
THE PRINCIPLES AND
PRACTICE OF MEDICINE
DESIGNED FOR THE USE OF PRACTITIONERS
AND STUDENTS OF MEDICINE
BY
WILLIAM OSLER, M.D.
FELLOW OF THE ROYAL SOCIETY ; FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS,
LONDON; REGIUS PROFESSOR OF MEDICINE, OXFORD UNIVERSITY; HONORARY PRO-
FESSOR OF MEDICINE, JOHNS HOPKINS UNIVERSITY, BALTIMORE ; FORMERLY
PROFESSOR OF THE INSTITUTE OF MEDICINE, McGILL UNIVERSITY,
MONTREAL, AND PROFESSOR OF CLINICAL MEDICINE IN THE
UNIVERSITY OF PENNSYLVANIA, PHILADELPHIA
SEVENTH EDITION, THOROUGHLY REVISED
NEW YORK AND LONDON
D. APPLETON AND COMPANY
1909
COPTRIGHT, 1892, 1895, 1898, 1901, 1903, 1903. 1904, 1905, 1909,
By D. APPLETON AND COMPANY
FEINTED AT THE APPLETON PEESS
NEW YOEK, U. S. A.
TO THE
ittetttorg of ms ®eacl)crs :
WILLIAM ARTHUR JOHNSON,
. PEIEST OP THE PARISH OF WESTON, ONTARIO.
JAMES BOVELL,
OF THE TORONTO SCHOOL OF MEDICINE, AND OF THE
UNIVERSITY OF TRINITY COLLEGE, TORONTO.
ROBERT PALMER HOWARD,
DEAN OF THE MEDICAL FACULTY AND PROFESSOR OF MEDICINE,
MCGILL UNIVERSITY, MONTREAL.
Digitized by the Internet Arciiive
in 2010 with funding from
Open Knowledge Commons
http://www.archive.org/details/principlespractiOOosle
PREFACE TO THE SEVENTH EDITION.
The three years that have passed since the last edition have been rich in
additions to our knowledge of disease and its treatment, particularly in con-
nection with the acute infections. I have incorporated all the more impor-
tant advances — the long-expected epoch-making discoveries in syphilis, the
work of the New York Pneumonia Commission, the triumph of the British
army and naval surgeons in stamping out Malta fever, the splendid work
of Gorgas and his colleagues at Panama, the studies of Strong and his asso-
ciates in the Philippine Islands, the fresh work which has been done in
trypanosomiasis psorosomiasis, tropical splenomegaly, the experiences of the
last epidemic of cerebro-spinal fever in New York, Belfast, and Glasgow, with
the hopeful work of Flexner at the Eockefeller Institute, the all-important
contributions on " carriers " in the acute infections, the results of the Wash-
ington Congress with the new views on infection, heredity, diagnosis, and
treatment of tuberculosis, the remarkable studies upon epidemic anterior
poliomyelitis, and the work upon Eocky Mountain fever, milk sickness, and
the serum disease. One cannot but be impressed with the extraordinary rapid-
ity of the progress of our knowledge of the acute infections !
The section on parasites has been carefully revised, and has received many
additions. In the chapters on the diseases of special organs much new matter
has been incorporated — a new section in acute dilation of the stomach, a
complete revision of the subject of peptic ulcer in the light of recent surgical
work, new sections on diverticulitis, parotitis, pancreatic and adrenal insuffi-
ciency, oedema of the lungs, Banti's disease, polycythsemia, etc. In the sec-
tion upon Diseases of the Nervous System the studies of Marie and his
pupils upon aphasia and the new work on spastic paraplegia, Oppenheim's
disease, posterior basic meningitis, psychasthenia, etc., have been incorporated.
The new points which have come up in treatment have been discussed,
particularly the important advances in serum therapy and on the surgical
treatment of internal diseases, and I have added a note on the cult of the day
vi: PREFACE TO THE SEVENTH EDITION.
— faith healing. In addition to these, scores of minor alterations have been
made, too numerous to mention.
Since the ajjpearance of the last edition the work has appeared in French,
translated by MM. Salomon and Lazard under the supervision of Professor
Marie (Steinheil & Cie., Paris) ; and in German, translated by Dr. Edmund
Hoke, with additions by Professor von Jaksch, of Prague. Spanish and Clii-
nese translations are in course of preparation.
I have many to thank — my fellow-teachers in the medical schools of the
English-speaking world for their kind reception of previous editions, many
friends for suggestions and advice, scores of practitioners all over the world
for interesting memoranda of cases; Dr. Broome, of Messrs. D. Appleton and
Comj)any, for his kind help in many ways, and my nephew. Dr. W. W. Erancis,
of Montreal, who has seen the proofs of this edition through the press.
William Oslek.
CONTENTS.
SECTION I.
DISEASES DUE TO ANIMAL PARASITES.
PAGE
A. Diseases due to Protozoa i
I. Psorospermiasis 1
II. Amoebic Dysentery 2
III. Trypanosomiasis 7
IV. Tropical Splenomegaly (Tropical Cachexia) 9
V. Malarial Fever 10
Intermittent Fever 16
Continued and Remittent Malarial Fevers 20
Pernicious Malarial Fever 21
Malarial Cachexia 23
B. Diseases due to Parasitic Infusoria 25
C. Diseases due to Flukes (Distomiasis) . . . . . . . . . . 26
D. Diseases caused by Cestodes 28
I. Intestinal Cestodes; Tape-worms 28
II. Visceral Cestodes 31
Cysticercus Cellulosse 31
Echinococcus Disease . . . ' 32
Multilocular Echinococcus 37
E. Diseases caused by Nematodes 38
I. Ascariasis . 38
II. Trichiniasis 39
III. Ankylostomiasis 44
IV. Filariasis _ 47
V. Dracontiasis 49
VI. Other Nematodes 50
Acanthocephala 51
F. Parasitic Arachnida and Ticks 52
G. Parasitic Insects 53
H. Parasitic Flies (Myiasis) 55
SECTION II.
SPECIFIC INFECTIOUS DISEASES.
I. Typhoid Fever 57
II. Typhus Fever . . . 105
III. Relapsing Fever 109
IV. Small-pox 112
Variola Vera 115
Hsemorrhagic Small-pox 117
Varioloid 119
V. Vaccinia (Cow-pox) — Vaccination 123
VI. Varicella (Chicken-pox) 128
VII. Scarlet Fever 130
VIII. Measles (Morbilli Rubeola) 140
IX. Rubella (Rotheln, German Measles) . 145
X. Epidemic Parotitis (Mumps) 146
XI- Whooping-cough ,,,,,, 148
vii
vni
CONTENTS.
XII.
XIII.
XIV.
XV.
XVI.
XVII.
XVIII.
XIX.
XX.
XXI.
XXII.
XXIII.
XXIV.
XXV.
XXVI.
XXVII.
XXVIII.
XXIX.
XXX.
XXXI.
XXXII.
XXXIII.
XXXIV.
XXXV.
Influenza.
Dengue .
Cerebro-spinal Fever
Pneumonia
Diphtheria
Erysipelas
Septicaemia and Pysemia
Septicaemia
Septico-Pyaemia .
Terminal Infections
Rheumatic Fever .
Cholera Asiatica .
Yellow Fever .
The Plague
Bacillary Dysentery
Malta Fever .
Beri-beri
Anthrax .
Hydrophobia .
Tetanus .
Glanders
Actinomycosis
Syphilis .
Acquired
Congenital .
Visceral
Gonorrhoeal Infection
Tuberculosis .
I. General Etiology and Morbid Anatomy
II. Acute Tuberculosis
III. Tuberculosis of the Lymphatic System
IV. " of the Lungs (Phthisis, Consumption)
V. " of the Alimentary Canal
VI. " of the Liver
VII. " of the Brain and Spinal Cord
VIII. " of the Genito-urinary System
IX. " of the Mammary Gland .
X. " of the Circulatory System
XI. Diagnosis of Tuberculosis
XII. Prognosis in Tuberculosis
XIII. .Prophylaxis in Tuberculosis .
XIV. Treatment of Tuberculosis
Leprosy
Infectious Diseases of Doubtful Nature
1. Febricula (Ephemeral Fever)
2. Infectious Jaundice (Weil's Disease)
3. Milk-sickness
4. Glandular Fever ....
5. Mountain Fever ....
6. Miliary Fever (Sweating Sickness)
7. Foot and Mouth Disease .
8. Psittacosis
9. Rocky Mountain Spotted Fever — ^Tick Fever
10. Swine Fever
CONTENTS.
IX
SECTION III.
THE INTOXICATIONS AND SUN-STROICE.
Alcoholism .
1. Acute Alcoholism
II.
III.
IV.
V.
VI.
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
2. Chronic Alcoholism
3. Delirium Tremens
Morphia Habit .
Lead Poisoning .
Arsenical Poisoning .
Food Poisoning .
1. Meat Poisoning .
2. Poisoning by Milk Products
3. Poisoning by Shell-fish and Fish
4. Grain and Vegetable Food Poisoning
Sun-s,troke
SECTION rv.
CONSTITUTIONAL DISEASES.
Arthritis Deformans
Chronic Rheumatism
Muscular Rheumatism ..,.„..
Gout .. = ..,
Diabetes Mellitus ..... o . .
Diabetes Insipidus . . . .
Rickets , . .
Obesity * .
PAGE
369
369
369
371
373
375
379
380
381
382
383
383
385
389
394
396
397
408
424
426
431
. SECTION V.
DISEASES OF THE DIGESTIVE SYSTEM.
A. Diseases of the Mouth 434
Stomatitis _ 434
Acute Stomatitis <> . . 434
Aphthous Stomatitis 434
Ulcerative Stomatitis . 435
Parasitic Stomatitis (Thrush) . . . 436
Gangrenous Stomatitis 437
Mercurial Stomatitis 437
Geographical Tongue (Eczema of the Tongue) ....... 438
Leukoplakia buccalis 439
Fetor Oris 439
Oral Sepsis •• = ...... 440
Affections of the Mucous Glands 440
B. Diseases of the Salivary Glands 440
Supersecretion , 440
Xerostomia 441
Inflammation of the Salivary Glands . . « , . . . o . .441
C. Diseases of the Pharynx ............. 442
Circulatory Disturbances 442
Acute Pharyngitis 442
Chronic Pharyngitis 443
Ulceration of the Pharynx 443
Acute Infectious Phlegmon of the Pharynx . . , . . . . . 444
Retro-pharyngeal Abscess 444
Angina Ludovici . , , . . . . . 444
X CONTENTS.
PAGE
D. Diseases of the Tonsils „ . . . . 445
I. Acute Tonsillitis 445
Follicular or Lacunar Tonsillitis ........ 445
Suppurative Tonsillitis 446
II. Chronic Tonsillitis 447
E. Diseases of the ffisophagus 451
■ I. Acute (Esophagitis 451
II. Spasm of the (Esophagus 453
III. Stricture of the (Esophagus - 453
IV. Cancer of the (Esophagus 454
V. Rupture of the (Esophagus 455
VI. Dilatations and Diverticula 456
F. Diseases of the Stomach 456
I. Acute Gastritis 456
Phlegmonous Gastritis 458
Toxic Gastritis 458
Diphtheritic Gastritis 459
Mycotic or Parasitic Gastritis ......... 459
II. Chronic Gastritis (Chronic Dyspepsia) 459
III. Dilatation of Stomach 467
IV. The Peptic Ulcer, Gastric and Duodenal 470
V. Cancer of Stomach 479
VI. Hypertrophic Stenosis of the Pylorus 486
VII. Hgemorrhage from the Stomach 487
VIII. Neuroses of the Stomach 490
G. Diseases of the Intestines . . • 497'
I. Diseases of the Intestines associated with Diarrhoea .... 497
Catarrhal Enteritis: Diarrhoea . . .• 497
Diphtheritic or Croupous Enteritis 500
Phlegmonous Enteritis 501
Ulcerative Enteritis 501
11. Diarrhoea! Diseases in Children ......... 504
III. Appendicitis (Typhlitis and Perityphlitis) 512
IV. Intestinal Obstruction 519
V. Constipation (Costiveness) 525
VI. Enteroptosis (Glenard's Disease) 528
VII. Miscellaneous Affections 530
Mucous Colitis 530
Dilatation of the Colon . . . .531
Intestinal Sand • 532
Diverticulitis — Perisigmoiditis 532
Affections of the Mesentery 532
H. Diseases of the Liver 534
I. Jaundice (Icterus) 534
II. Icterus Neonatorum 538
III. Acute Yellow Atrophy 538
IV. Affections of the Blood-vessels of the Liver 540
V. Diseases of the Bile-passages and Gall-bladder 542
VI. Cholelithiasis 548
VII. Cirrhoses of the Liver 556
VIII. Abscess of the liiver . 563
IX. New Growths in the Liver 567
X. Fatty Liver 570
XI. Amyloid Liver 571
XII. Anomalies in Form and Position of the Liver ,,,,.. 572
CONTENTS.
XI
PAGE
I. Diseases of the Pancreas 573
I. Insufficiency 573
II. Hsemorrhage 573
III. Acute Pancreatitis 574
IV. Chronic Pancreatitis 577
V. Pancreatic Cysts ■ 577
VI. Tumors of the Pancreas 579
VII. Pancreatic Calcuh . . . • 530
J. Diseases of the Peritonaeum 5g0
I. Acute General Peritonitis 580
II. Peritonitis in Infants 534
III. Localized Peritonitis 584
IV. Chronic Peritonitis 586
V. New Growths in the Peritonaeum 588
VI. Ascites (Hydro-peritonseum) 589
SECTION VI.
DISEASES OF THE RESPIRATORY SYSTEM.
A. Diseases of the Nose 593
I. Acute Coryza 593
II. Autumnal Catarrh (Hay Fever) 594
III. Epistaxis 595
B. Diseases of the Larynx 595
I. Acute Catarrhal Laryngitis , 596
II. Chronic Laryngitis _ 597
III. Edematous Laryngitis 598
IV. Spasmodic Laryngitis (Laryngismus stridulus) 598
V. Tuberculous Laryngitis 6qq
VI. Syphilitic Laryngitis gQj
C. Diseases of the Bronchi . ' g02
I. Acute Bronchitis . , 6Q2
II. Chronic Bronchitis 594
III. Bronchiectasis qqq
IV. Bronchial Asthma 609
V. Fibrinous Bronchitis 513 '
D. Diseases of the Lungs gl4
I. Circulatory Disturbances in the Lungs 614
II. Broncho-pneumonia (Capillary Bronchitis) 620
III. Chronic Interstitial Pneumonia (Cirrhosis of Lung) 628
IV. Pneumonokoniosis 631
V. Emphysema 633
Compensatory Emphysema . 633
Hypertrophic Emphysema 634
Atrophic Emphysema 638
Acute Vesicular Emphysema . 638
Interstitial Emphysema 638
VI. Gangrene of the Lung 638
VII. Abscess of the Lung 640
VIII. New Growths in the Lungs 641
E. Diseases of the Pleura 643
I. Acute Pleurisy 643
Fibrinous or Plastic Pleurisy ...00.... 643
Sero-fibrinous Pleurisy . . . 643
Purulent Pleurisy (Empyema) 648
xii CONTENTS.
PAGE
Tuberculous Pleurisy 650
Other Varieties of Pleurisy 650
II. Chronic Pleurisy 655
III. Hydrothorax . 656
IV. Pneumothorax (Hydro-pneumothorax and Pyo-pneumothorax) . . 657
V. Affections of the Mediastinum 660
SECTION VII.
DISE.\SES OF THE KIDNEYS.
I. Malformations 664
II. Movable Kidney 664
III. Circulatory Disturbances 667
IV. AnomaHes of the Urinary Secretion 668
1. Anuria 668
2. Haematuria 669
3. Haemoglobinuria . , 670
4. Albuminuria 672
5. Pyuria (Pus in the Urine) 676
6. Chyluria (Non-parasitic) 676
7. Lithuria ... ... , 677
8. Oxaluria ................ 678
9. Cystinuria 679
10. Phosphaturia . . . o 679
11. Indicanuria ......... .... 680
12. Melanuria 680
13. Alkaptonuria and Ochronosis . 681
14. Pneumaturia 681
15. Other Substances ............ 682
V. Uraemia 683
VI. Acute Bright' s Disease ............ 686
VII. Chronic Bright's Di.sea.se ............ 692
Chronic Parenchymatous Nephritis . , ■ . 692
Chronic Interstitial Nephritis ........... 694
VIII. Amyloid Disease .702
IX. Pyelitis 703
X. Hydronephrosis 707
XL Nephrohthiasis (Renal Calculus) .„ ... 709
XII. Tumors of the Kidney » .... 713
XIII. Cystic Disease of the Kidney o 715
XIV. Perinephric Abscess 717
SECTION VIII.
DISEASES OF THE BLOOD AND DUCTLESS GLANDS.
I. Ansemia 718
Secondary Ansemia 719
Primary or Essential Ansemia 721
II. Leuksemia 731
III. Hodgkin's Disease 738
IV. Purpura 742
V. Hsemophilia 747
VI. Scurvy . 750
VII. Status L;\Tnphaticus (L\Tnphatism) . ... ...... 755
VIII. Diseases of the Suprarenal Bodies 756
Addison's Disease 756
CONTENTS. xiii
PAGE
IX. Diseases of the Spleen 760
Movable Spleen 760
Rupture of the Spleen 761
Infarct and Abscess of the Spleen 761
Splenomegaly 762
Chronic Polycythsemia with Cyanosis and Enlarged Spleen .... 762
X. Diseases of the Thyroid Gland . . . o 763
Congestion 763
Acute Thyroiditis .763
Goitre 763
Tumors of the Thyroid 764
Exophthalmic Goitre 765
Myxoedema 768
XI. Diseases of the Thymus Gland 771
XII. Infantilism 773
SECTION IX.
DISEASES OF THE CIRCULATORY SYSTEM.
Diseases of the Pericardium 775
I. Pericarditis 775
II. Other Affections of the Pericardium 784
Diseases of the Heart 785
I. Endocarditis 785
Acute Endocarditis 785
Chronic Endocarditis ....;...,,. 792
II. Chronic Valvular Disease ......' 793
General Introduction 793
Aortic Incompetency ..«.-<...,.. 796
Aortic Stenosis 802
Mitral Incompetency 804
Mitral Stenosis 808
Tricuspid Valve Disease . .811
Pulmonary Valve Disease . , . 813
Combined Valvular Lesions .......... 813
III. Affections of the Myocardium .......... 820
Dilatation and Hypertrophy 820
Lesions due to Disease of the Coronary Arteries 823
Acute Interstitial Myocarditis 824
Fragmentation and Segmentation 825
Parenchymatous Degeneration 825
Fatty Heart . ■ 825
Other Degenerations of the Myocardium . 826
IV. Aneurism of the Heart 830
V. Rupture of the Heart 830
VI. New Growths and Parasites 831
VII. Wounds and Foreign Bodies 831
VIII. Functional Affections of the Heart 832
Palpitation 832
Arrhythmia 833
Rapid Heart (Tachycardia) . . o . ., , . . . 835
Slow Heart (Bradycardia) Heart Block . . . , „ . . 836
Heart Block (Stokes- Adams Disease) 837
xiv ■ CONTENTS.
PAGE
IX. Angina Pectoris 839
X. Congenital Affections of the Heart 843
C. Diseases of the Arteries 847
I. Degenerations 847
II. Arterio-sclerosis (Arterio-capillary Fibrosis) 847
III. Aneurism 853
Aneurism of the Thoracic Aorta 855
Aneurism of the Abdominal Aorta 863
Aneurism of the Branches of the Abdominal Aorta. .... 865
Arterio-venous Aneurism 865
Polyarteritis Acuta Nodosa (Periarteritis Nodosa) .... 866
SECTION X.
DISEASES OF THE NERVOUS SYSTEM.
A. General Introduction 867
B. System Diseases 885
I. Introduction 885
II. Diseases of the Afferent or Sensory System 886
Locomotor Ataxia 886
General Paralysis of the Insane and Tabo-Paralysis .... 895
Herpes Zoster 900
III. Diseases of the Efferent or Motor Tract 901
A. Of the whole Tract 901
Progressive (Central) Muscular Atrophy 901
Bulbar Paralysis 904
Progressive Neural Muscular Atrophy ...... 905
The Muscular Dystrophies ......... 906
B. System Diseases of the Upper Motor Segment 909
Spastic Paralysis of Adults 909
Spastic Paralysis of Infants 910
Hereditary Spastic Paraplegia .912
Erb's Sj^philitic Spinal Paralysis 913
Secondary Spastic Paralysis 913
Hysterical Spastic Paraplegia .' 914
C. System Diseases of the Lower ^lotor Segment 914
Chronic Anterior Polio-myelitis . .914
Ophthalmoplegia . . .914
Acute Anterior Polio-myelitis - . .914
Acute and Subacute Polio-myelitis in Adults ..... 918
Acute Ascending (Landry's) Paralysis 918
IV. Combined System Diseases 919
Ataxic Paraplegia 920
Primary Combined Sclerosis (Putnam) 920
Hereditary Ataxia (Friedreich's Ataxia) 921
Progressive Interstitial Hj-pertrophic Neuritis of Infants . . . 922
Toxic Combined Sclerosis 922
C. Diffuse Diseases of the Nervous System 923
I. Affections of the Meninges 923
Diseases of the Dura Mater (Pachymeningitis) 923
Hsemorrhagic Pachymeningitis . . . . = . . . . 923
Diseases of the Pia Mater ..... o«.. . 925
Simple Meningitis of Infants .0.00 = 00. 928
TI. Scleroses of the Brain . . , <, » » » o « o . 928
CONTENTS. XV
PAGE
D. Diffuse and Focal Diseases of the Spinal Cord ........ 931
I. Topical Diagnosis 931
II. Affections of the Blood-vessels 934
Congestion 934
Ansemia 934
Embolism and Thrombosis 935
Endarteritis 935
Haemorrhage into the Spinal Membranes » . 935
Haemorrhage into the Spinal Cord 936
Caisson Disease 937
III. Compression of the Spinal Cord 938
Lesions of the Cauda Equina and Conus MeduUaris .... 940
IV. Tumors of the Spinal Cord and its Membranes 941
V. Syringomyelia • 943
IV. Acute Myelitis 944
E. Diffuse and Focal Diseases of the Brain . 947
I. Topical Diagnosis .... o ....-• - 947
II. Aphasia 955
III. Affections of the Blood-vessels . 961
Cerebral Circulation . . . .961
Hypersemia and Anaemia 964
CEdema of the Brain 965
Cerebral Haemorrhage 966
Embolism and Thrombosis . 977
Aneurism of the Cerebral Arteries - . • 982
Endarteritis 983
Thrombosis of the Cerebral Sinuses and Veins 983
Hemiplegia in Children . 985
IV. Tumors, Infectious Granulomata, and Cysts of the Brain .... 988
V. Inflammation of the Brain 992
Acute Encephalitis 992
Abscess of the Brain 993
VI. Hydrocephalus 996
F. Diseases of the Peripheral Nerves 998
I. Neuritis (Inflammation of the Bundles of Nerve Fibres) .... 998
II. Neuromata 1004
III. Diseases of the Cerebral Nerves 1005
Olfactory Nerves and Tracts 1005
Optic Nerve and Tract 1006
Lesions of the Retina 1006
Lesions of the Optic Nerve • • 1008
Affections of the Chiasma and Tract 1009
Affections of the Tract and Centres ....... 1010
Motor Nerves of the Eyeball 1013
Fifth Nerve 1017
Facial Nerve 1019
Auditory Nerve 1023
The Cochlear Nerve 1023
The Vestibular Nerve 1024
Glosso-pharyngeal Nerve . . . . . o » . . ■ 1026
Pneumogastric Nerve ..... o...- • 1027
Spinal Accessory . . . . . • 1030
Hypoglossal Nerve. . . . . « . . . • • • 1032
xvi CONTENTS.
PAGti
IV. Diseases of the Spinal Nerves ....,...,. 1033
Cervical Plexus ............ 1033
Brachial Plexus ............ 1035
Lumbar and Sacral Plexuses ......... 1038
Sciatica 1039
G. General and Functional Diseases 1041
I. Acute Delirium (Bell's Mania) 1041
II. Paralysis Agitans 1042
Other Forms of Tremor 1044
III. Acute Chorea (Sydenham's Chorea; St. Vitus's Dance) .... 1045
IV. Other Affections described as Chorea 1053
V. Infantile Convulsions (Eclampsia) - 1056
VI. Epilepsy . 1058
VII. Migraine 1066
VIII. Neuralgia 1068
IX. Professional Spasms; Occupation Neuroses . • . . . . . 1072
X. Tetany 1074
XI. Hysteria 1076
XII. Neurasthenia 1086
XIII. The Traumatic Neuroses 1096
XIV. Other Forms of Functional Paralysis 1099
Periodical Paralysis 1099
Astasia; Abasia ............ 1099
H. Vaso-motor and Trophic Disorders .......... 1100
I. Raynaud's Disease ............ 1100
II. Erythromelalgia ............ 1102
III. Angio-neurotic (Edema ........... 1103
IV. Facial Hemiatrophy 1104
V. Acromegaly ............. 1105
Osteitis Deformans ........... 1106
Hypertrophic Pulmonary Arthropathy ....... 1107
Leontiasis Ossea 1107
Osteogenesis Imperfecta 1108
Achondroplasia (Chondrodystrophia Foetalis) ...... 1108
VI. Scleroderma 1109
Ainhum 1110
SECTION XI.
DISEASES OF THE MUSCLES.
I. Myositis 1111
1112
1113
1113
1114
II. Myotonia (Thomsen's Disease)
III. Paramyoclonus Multiplex
IV. Myasthenia Gravis
V. Amyotonia congenita (Oppenheim's Disease)
CHAETS AND ILLUSTEATIONS.
la. Malaria — Double Tertian Infection — Quotidian Fever ..... 18
lb. ^stivo-autumnal Infection — Remittent Fever . . . . . . .18
Ic. ^stivo-autumnal Fever — Quotidian Paroxysms . . . . . .19
Id. Quartan Fever 19
II. Typhoid Fever with Relapse ........... 73
III. Illustrating the Blood Changes in Typhoid Fever ...... 77
IV. Typhoid Fever — Haemorrhage from the Bowels* 81
V. Illustrating Influence of Baths in Typhoid Fever . . . . . . 101
VI. Relapsing Fever (after Murchison) Ill
VII. Small-pox (after Striimpell) 116
VIII. Scarlet Fever 133
IX. Measles 142
X. Temperature, Pulse, and Respiration Chart in Pneumonia .... 173
XL Showing Coincident Drop in the Fever and in the Leucocytes in Pneumonia. 178
XII. Chronic Tuberculosis, Two-hourly Chart for Three Days .... 328
XIII. Case of Sun-stroke treated with Ice-bath. Recovery. (Rectal Temperatures). 387
XIV. Showing LTric Acid and Phosphoric Acid Output in a Case of Acute Gout . 402
XV. Illustrating Influence of Diet on Sugar and Amount of LTrine in Diabetes . 422
XVI. Blood Chart, illustrating Ansemia in Purpura Haemorrhagica .... 720
XVII. Blood Chart, illustrating Chlorosis 723
XVIII. Blood Chart, illustrating Pernicious Ansemia 727
XIX. Blood Chart, illustrating Leukaemia 735
XX. Blood Chart, illustrating Rapid Production of Anaemia in Purpura Haem-
orrhagica . 746
XXI. Diagrams after Martins, showing schematically the Power of the Heart
Muscle . . . .794
XXII. Schematic Division of the Phases of the Heart's Action (Martins) . . 796
1
2
3
4
5
6
7,8,
9
10
Diagram of Motor Path from Left Brain (Van Gehuchten) .... 869
Diagram of Motor Path (Van Gehuchten) 870
Diagram of Cerebral Localization 874
Diagram of Motor and Sensory Representation in the Internal Capsule . 875
Diagram of Motor and Sensory Paths in Crura 876
Diagram of Cross-section of Spinal Cord 876
Diagrams of Skin Areas corresponding to the Different Spinal Segments, 878, 879
Diagram of Motor Path from Left Brain 972
Diagram of Visual Paths (Vialet) 1011
* The red shows the two-hourly, the black the morning and evening temperature.
1 xvii
A TEXT-BOOK ON
THE PRACTICE OF MEDICINE.
SECTION I.
DISEASES DUE TO ANIMAL PAEASITES.
A. DISEASES DUE TO PROTOZOA.
I. PSOROSPERMIASIS.
Under this term are embraced several affections produced by the spo-
rozoa — also known as psorosperms and gregarinidae — parasites which are
extraordinarily abundant in the invertebrates^, and are not uncommon in the
higher mammals. Psorosperms are, as a rule, parasites of the cells — Cytozoa.
The most suitable form for study is Coccidium oviforme of the rabbit, which
produces a disease of the liver in which the organ is studded throughout with
whitish nodules, ranging in size from a pin's head to a split pea. On section
each nodule is seen to be a dilated portion of a bile-duct; the walls are lined
with epithelium in the interior of which are multitudes of ovoid bodies — coc-
cidia. Another very common form occurs in the muscles of the pig, the
so-called Eainey's tube, which is an ovoid body within the sarcolemma contain-
ing a number of small, sickle-shaped, unicellular organisms, Sarcocystis Mies-
cheri. Another species, S. Jiominis, has been described in man.
Psorosperms do not play a very important role in human pathology.
1. Internal Psorospermiasis. — In a majority of the cases of this group
the psorosperms have been found in the liver, producing a disease similar
to that which occurs in rabbits. In Guebler's case there were tumors which
could be felt during life, and they were determined by Leuckart to be due
to coccidia. A patient of W. B. Haddon's was admitted to St. Thomas's
Hospital with slight fever and drowsiness, and gradually became unconscious ;
death occurring on the fourteenth day of observation. Whitish neoplasms
were found upon the peritonaeum, omentum, and on the layers of the peri-
cardium; and a few were found in the liver, spleen, and kidneys. A some-
what similar case, though more remarkable, as it ran a very acute course, is
reported by Silcott. A woman, aged fifty-three, admitted to St. Mary's Hos-
pital, was thought to be suffering from typhoid fever. She had had a chill
six weeks before admission. There were fever of an intermittent type, slight
diarrhoea, nausea, tenderness over the liver and spleen, and a dry tongue;
death occurred from heart-failure. The liver was enlarged, weighed 83
ounces, and in its substance there were caseous foci, around each of which
was a ring of congestion. The spleen weighed 16 ounces and contained sim-
3 1
2 DISEASES DUE TO ANIMAL PARASITES.
ilar bodies. The ileum presented six papiile-like elevations. The masses
resembled tubercles, but on examination coccidia were found.
The parasites are also found in the kidneys and ureters. Cases of this
kind have been recorded by Bland Sutton and Paul Eve. In Eve's case
the symptoms were liEematuria and frequent micturition, and death took
place on the seventeenth day. The nodules throughout the pelvis and ureters
have been regarded as mucous cysts.
2. Cutaneous Psorospermiasis. — The question of a protozoic dermatitis
has been much discussed. The cases described by Gilchrist, Darier, Eixford,
Montgomery, Ophiils, and others as dermatitis coccidoides have been shown
to be due to a fungus allied to oidium, and the disease is now known as
oidiomycosis. About 50 cases have been reported, nearly all from the Pacific
coast of the United States. The relation of the disease to blastomycosis is
still undetermined. The systemic forms of both have much in common — a
chronic infectious process with multiple abscesses and nodules involving the
skin, bones, joints, and internal organs, with symptoms simulating chronic
tuberculosis or pyaemia.
II. AMCEBIC DYSENTERY.
Definition. — A colitis, acute or chronic, caused by the Amcebic dysen-
terice. There is a special liability to the formation of abscess of the liver.
A widely prevalent disease in Egypt, in India, and in tropical countries. It
is the common variety of dysentery throughout the United States. It is
endemic, the cases sometimes increasing to such an extent as to form an epi-
demic. Sporadic instances apparently occur in all temperate regions. The
relative frequency of this form of dysentery in the tropics is illustrated by the
Manila statistics as given by Strong — of 1,328 cases in the United States
Army, 561 were of the amoebic variety. The cases of acute and chronic dysen-
tery in the Johns Hopkins Hospital have been almost exclusively amoebic.
Futcher and Boggs have analyzed the cases to 1908. Of 182, 123 came from
the State of Maryland, 171 were in males; 163 in whites to 19 in blacks.
Infection takes place from drinking contaminated water and by eating
green vegetables, such as lettuce. Musgrave has grown amoebae from ice-
cream used at receptions, etc.
Amceba Dysenteric. — The organism was first described by Lambl in
1859, and subsequently by Losch in 1875. It is placed by Leuckart in the
Rhizopoda class of the Protozoa. Kartulius found them in the stools of the
endemic dysentery in Egypt, and in the liver abscesses. In 1890 I found them
in a case of dysentery with abscess of the liver originating in Panama. Sub-
sequently from my wards a series of cases was described by Councilman and
Lafleur. Since then numbers of observations have been made by Dock in the
United States, by Quincke and Roos in Germany, and by many others. The
little flakes of mucus or pus in the stools should be selected for examination
or the mucus obtained by passing a soft-rubber catheter. Musgrave, on the
other hand, holds that the best results are obtained by giving the patient a
saline cathartic and examining the fluid portion of the stool. Students must
learn to distinguish from amoebae the swollen, altered epithelial cells, which
are round, with granular protoplasm.
DISEASES DUE TO PROTOZOA. 3
Amoeba or Entamoeba dysenterice is from fifteen to twenty ix in diameter,
and consists of a clear outer zone (ectosarc), and a granular inner zone (endo-
sarc), and contains a nucleus and one or two vacuoles. The movements are
very similar to those of the ordinary amoeba, consisting of slight protrusions
of the protoplasm. They vary a good deal, and usually may be intensified by
having the slide heated. Not infrequently the amoebae contain red blood-
corpuscles which they have included. In the tissues they are very readily
recognized by suitable stains. They may be in enormous numbers, and some-
times the field of the microscope is completely occupied by them. In the
pus of a liver abscess they may be very abundant, though in large, long-stand-
ing abscesses they may not be found until after a few days, when the pus begins
to discharge from the wall of the abscess cavity. In the sputum in the cases of
pulmono-hepatic abscess they are readily recognized.
Amoebae are frequently found in the stools of healthy persons, as Cunning-
ham and Lewis pointed out. Schaudinn found them in from 20 to 60 per
cent in Germany, but they vary greatly in different localities. Among 300
persons in Manila, Musgrave found 101 infected with amoebae, 61 of these
had dysentery, the remaining 40 had no diarrhoea. In the next two months
8 of the 40 cases died and showed amoebic infection of the bowel. Within
the next three months the remaining 32 had dysentery. Musgrave believes
that at any time the amoeba may become pathogenic. Schaudinn described
two distinct forms — a nonpathogenic Entamwbi coli, and a pathogenic larger
form, the Entamoeba histolytica, the same as the Amoeba dysenterice, with a
strongly refractile hyaline ectoplasm. The amoebae have been cultivated by
Miller, Musgrave, Clegg, and others, but with difficulty, and it is doubtful
if they grow apart from certain bacteria. Eesistant forms, somewhat anal-
ogous to the gamete forms of the malarial parasite, have been described by
Cunningham, Grassi and Calandruccio, and by Quincke. These "encysted
amoebae ■ ' are believed to be necessary, under certain conditions, for the trans-
mission of the disease from one person to another, and are regarded by Mus-
grave and Clegg as the most dangerous forms of the organism. Cultures of
amoebse have been shown to withstand drying for from eleven to fifteen months.
Morbid Anatomy. — The lesions are found in the large intestine, some-
times in the lower portion of the ileum. Abscess of the liver is very common,
and occurred in 37 of 182 cases at the Johns Hopkins Hospital.
Intestines. — The lesions consist of ulceration, produced by preceding
infiltration, general or local, of the submucosa, due to an oedematous condition
and to multiplication of the fixed cells of the tissue. In the earliest stage
these local infiltrations appear as hemispherical elevations above the general
level of the mucosa. The mucous membrane over these soon becomes necrotic
and is cast off, exposing the infiltrated submucous tissue as a grayish-yellow
gelatinous mass, which at first forms the floor of the ulcer, but is subsequently
cast off as a slough.
The individual ulcers are round, oval, or irregular, with infiltrated,
undermined edges. The visible aperture is often small compared to the loss
of tissue beneath it, the ulcers undermining the mucosa, coalescing, and form-
ing sinuous tracts bridged over by apparently normal mucous membrane.
According to the stage at which the lesions are observed, the floor of the ulcer
may be formed by the submucous, the muscular, or the serous coat of the
4 DISEASES DUE TO ANIMAL PARASITES.
intestine. Tlie ulceration may affect tlie whole or some portion only of the
large intestine, particularly the cgecum, the hepatic and sigmoid flexures, and
the rectum. In severe cases the whole of the intestine is much thickened and
riddled with ulcers, with only here and there islands of intact mucous mem-
brane. In 100 autopsies on this disease in Manila the appendix was involved
in 7 ; perforation of the colon took place in 19.
The disease advances by progressive infiltration of the connective-tissue
laj^ers of the intestine, which produces necrosis of the overlying structures.
Thus, in severe cases there may be in different parts of the bowel sloughing
en masse of the mucosa or of the muscularis, and the same process is observed,
but not so conspicuously, in the less severe forms.
In some cases a secondary diphtheritic inflammation complicates the origi-
nal lesions.
Healing takes place by the gradual formation of fibrous tissue in the floor
and at the edges of the ulcers, which may ultimately result in partial and
irregular strictures of the bowel.
Microscoj)ical examination shows a notable absence of the products of puru-
lent inflammation. In the infiltrated tissues polynuclear leucocytes are sel-
dom found, and never constitute purulent collections. On the other hand,
there is proliferation of the fixed connective-tissue cells. Amoebee are found
more or less abundantly in the tissues at the base of and around the ulcers, in
the lymphatic spaces, and occasionally in the blood-vessels. The portal
capillaries occasionally contain them, and this fact seems to afford the best
explanation for the mode of infection of the liver.
The lesions in the livei' are of two kinds: first, local necroses of the
parenchj^ma, scattered throughout the organ, and possibly due to the action
of chemical products of the amoebas; and, secondly, abscesses. These may
be single or multiple. There were 27 cases of hepatic abscess among the 119
cases of amoebic dysentery in my wards. Of these, 18 came to autopsy. In
10 the abscess was single and in 8 multiple. When single they are generally
in the right lobe, either toward the convex surface near its diaphragmatic
attachment, or on the concave surface in proximity to the bowel. Multiple
abscesses are small and generally superficial. There may be innumerable
miliary abscesses containing amoebse scattered throughout the entire liver.
Although the hepatic abscess usualh" occurs within the first two months from
the onset of the dysenterj'-, in one of my cases the latter had lasted one and
in another six years. In 5 cases the intestinal symptoms had been so slight
that dysentery had never been complained of. In 2 fatal cases there were only
scars of old ulcers and in 2 others the mucosa appeared normal. In an early
stage the abscesses are gra}ash-yellow, with sharpily defined contours, and con-
tain a spongy necrotic material, with more or less fluid in its interstices. The
larger abscesses have ragged necrotic walls, and contain a more or less viscid,
greenish-3-ellow or reddish-yellow purulent material mixed with blood and
shreds of liver-tissue. The older abscesses have fibrous walls of a dense,
almost cartilaginous toughness. A section of the abscess wall shows an inner
necrotic zone, a middle zone in which there is great proliferation of the con-
nective-tissue cells and compression and atrophy of the liver-cells, and an outer
zone of intense hypera^mia. There is the same absence of purulent inflam-
mation as in the intestine, except in those cases in which a secondary infec-
DISEASES DUE TO PROTOZOA. 5
tion with p3'0genic organisms has taken place. Lesions in the kings are seen
when an abscess of the liver — as so frequently happens — points toward the
diaphragm and extends by continuity through it into the lower lobe of the
right lung. This is the commonest situation for rupture to occur. Nine of
my cases ruptured into the lung. In 3 cases rupture into the right pleura
occurred, causing an empyema. In one of these the lung abscess ruptured
into the pleura, producing a pyo-pneumothorax. Depending upon the situa-..
tion of the abscess, perforation may occur into other adjacent structures. In
3 of the cases perforation took place into the inferior vena cava and in another
the upper pole of the right kidney had been invaded. The abscess may rupture
into the pericardium, peritonseimi, stomach, intestine, portal and hepatic veins,
or externally.*
Symptoms. — Differing remarkably in their symptoms, three groups of cases
may be recognized :
Mild Form. — Infection may be present for a month or two before the
individual is aware of it. There may be vague spnptoms — headache, lassitude,
weakness, slight abdominal pains and occasional diarrhoea, features common
enough in the tropics. Strong gives the case of one of his laboratory chemists
who had slight diarrhoea for one day and asked to have the stools examined;
an unusually rich infection with amoeba was found. The next day he felt well.
From August to December 10th amcebge were present in the stools, though he
had no s3anptoms. Liver abscess may occur in these cases.
Acute x4mcebic Dysentery. — Many cases have an acute onset. Pain and
tenesmus are severe. The stools are bloody, or mucus and blood occur to-
gether. In very severe cases there may be constant tenesmus, with pain of
the greatest intensity, and the passage every few minutes of a little blood and
mucus. In some cases large sloughs are passed. The temperature as a rule
is not high. The patient may become rapidly emaciated; the heart's action
becomes feeble, and death may occur within a week of the onset. Among
the other symptoms to be mentioned are haemorrhage from the bowels, which
occurred in three cases ; perforation of an ulcer, which occurred in three cases,
with general peritonitis. While in a majority of the instances the patient
recovers, in others the disease drags on and becomes chronic. In a few cases,
after the separation of the sloughs, there is extensive ulceration remaining,
with thickening and induration of the colon, and the patient has constant
diarrhoea, loses weight, and ultimately dies exhausted, usually within three
months of the onset. With the exception of cancer of the oesophagus and
anorexia nervosa, no such extreme grade of emaciation is seen as in these
cases. Extensive ulceration of the cornea may occur.
Chroxic Amcebic Dysentery. — The disease may be subacute from the
onset, and gradually passes into a chronic stage, the special characteristic of
which is alternating periods of constipation and of diarrhoea. These 'may
occur over a period of from six months to a year or more. Some of our
patients have been admitted to the hospital five or six times within a period
of two years. During the exacerbations there are pain, frequent passages of
mucus and blood, and a slight rise of temperature. Many of these patients do
not feel very ill, and retain their nutrition in a remarkable way; indeed, in
the United States it is rare to see the extreme emaciation so common in the
* For a full account of Hepatic Abscess see Rolleston's work on Diseases of the Liver.
6 DISEASES DUE TO ANIMAL PARASITES.
chronic cases from the tropics. Alternating periods of improvement with
attacks of diarrhoea are the rule. The appetite is capricious, the digestion
disordered, and slight errors in diet are apt to be followed at once by an
increase in the number of stools. The tongue is often red, glazed, and beefy.
In protracted cases the emaciation may be extreme.
Complications and Sequelae. — Hepatic and hepato-pulmonary abscesses,
the most frequent and serious complications, have already been dealt with.
Perforation of the intestine and peritonitis occurred in three of my cases.
Intestinal haemorrhage occurred three times. The infrequency of this com-
plication is probably due to the thrombosis of the vessels about the areas of
infiltration. Occasionally an arthritis, probably toxic in origin, may occur.
There was one case in my series. Five cases were complicated by malaria;
1 by typhoid fever; 1 by pulmonary tuberculosis; and 1 by a strongyloides
intestinalis infection.
Diagnosis. — From the other forms of dysenter}- the disease is recog-
nized by the finding of amcebse in the stools. Unless one sees undoubted
amoeboid movement a suspected body should not be considered an amoeba.
A non-motile body containing one or more red cells is most probably an
amoeba, but should only lead to further search for motile organisms. Swollen
epithelial cells are confusing, but the hyaline periphery is not amoeboid
in its action as is the ectosarc of the amoeba. The trichomonads and cerco-
monads so frequently associated with amoebge are not likely to give trouble.
The upper level of liver dulness should be watched throughout the course
of a case. Any increase upward or downward should lead to the suspicion
of a liver abscess. Hepatic abscess is usually accompanied by fever, sweats, or
chills and local pain. It may be entirely latent. A varying leucocytosis
occurs in the abscess cases. The highest count in my series was 53,000, the
average being 18,350. The average leucocyte count in the uncomplicated
dysentery cases was 10,600. Hepato-pulmonary abscess is attended by local
lung signs and the expectoration of " anchovy sauce " sputum in which amoebse
are almost invariably found.
Prognosis. — In many cases the disease yields to rest and intestinal medi-
cation. Tendency to a relapse of the dysenteric symptoms is one of the strik-
ing characteristics of the disease. One of my cases was admitted to the
hospital five times in nine months. Of the 119 cases, 28, or 23.5 per cent,
terminated fatally. That hepatic abscess is a serious complication is shown
by the fact that of the 27 cases with this complication 19 died. Seventeen
cases were operated on with 5 recoveries.
Treatment. — The disease is probably contracted in identically the same
way as typhoid fever. Accordingly, the same prophylactic measures should
be used. Eest in bed is very important and materially hastens recovery.
The diet should be governed by the severity of the intestinal manifestations.
In the very acute cases the patient should be given a liquid diet, consisting of
milk, whey, and broths. Medicines administered internally yield, on the
whole, very unsatisfactory results. Considering the fact that other bacteria
are necessary for the growth of the amoeb£e in the intestine, Musgrave thinks
that an effort should be made to limit the growth of the former by the admin-
istration of intestinal antiseptics. None of these have proved very satisfac-
tory, however, although Strong obtained good results with the use of aceto-
DISEASES DUE TO PROTOZOA. 7
zone administered by mouth and by enema. Bismuth probably does more
harm than good owing to the fact that it coats the surface of the ulcers so
that the solutions used in the injections can not reach the amoebae in the ulcer
walls. Large injections of quinine solution in the strength of 1 to 5,000,
gradually increasing to 1 to 2,500, and later to 1 to 1,000, have given most
satisfactory results of all the remedies yet tried. The success of the treatment
depends largely on the care with which the injections are given. The failures
are undoubtedly, in many instances, due to the fact that sufficient care is not
used to insure the solution reaching the caecum and ascending colon where the
ulceration is often most severe. From a litre to two litres should be allowed
to flow into the colon. The amoebae are rapidly destroyed by the drug. The
patient's hips should be elevated and he should change his position so as to
allow the fluid to flow into all parts of the colon. The solution should be
retained, if possible, for fifteen minutes. These large injections, which Mus-
grave also strongly advocates, are said not to be without a certain degree of
danger. I have, however, never seen any ill effects, even with the very large
amoiints. Two injections daily may be given. When there is much tenesmus
a small injection of thin starch and half a drachm to a drachm of laudanum
gives great relief; but for the tormina and tenesmus, the two most distressing
symptoms, a hypodermic of morphia is the only satisfactory remedy. Local
application to the abdomen, in the form of light poultices, or turpentine stupes
are very grateful. Tuttle has recently reported good results in the treatment
of amoebic dysentery by the use of simple ice-water enemas, given frequently.
When medical treatment fails, colostomy may be tried or irrigations given
through the appendix.
III. TRYPANOSOMIASIS.
Definition. — A chronic disorder characterized by fever, lassitude, weak-
ness, wasting, and often a protracted lethargy — sleeping sickness. Trypano-
soma gamhiense is the active agent in the disease.
History. — In 1843 Gruby found a blood parasite in the frog which he
called Trypanosoma sanguinis. Subsequently it was found to be a very com-
mon blood parasite in fishes and birds. In 1878 Lewis found it in the rat —
T. lewisii — in which it apparently does no harm. The pathological signifi-
cance of the protozoa was first suggested in 1880 by Griffith Evans, who discov-
ered trypanosomes — T. evansii — in the disease of horses and cattle in India
known as snrra. Unfortunately, as my good friend Evans often complained
to me, but little attention was paid to this really radical discovery — not even
the subsequent studies of Laveran on malaria and of Theobald Smith on
Texas fever stirred workers to a recognition of the place of the protozoa as
pathogenic agents. In 1895 Bruce made the important announcement that
the tsetze fly disease or nagana of South Africa, which made whole districts
impassable for cattle and horses, was really due to a trypanosome — T. hrucei.
Normally present in the blood of the big-game animals of the districts, and
doing them no harm, it was conveyed by the tsetze fly to the non-immune horses
and cattle imported into what were called the fly-belts. Other trypanosomes
are the Philippine surra, studied by Musgrave, the mal de caderas — T. equi-
8 DISEASES DUE TO ANIMAL PARASITES.
num — of South America and a harmless infection in cattle in the Transvaal
caused by Trypanosoma theileri.
Human Trypanosomiasis. — In 1901 Button found a trypanosome in the
blood of a West Indian. In 1903 Castellani found trypanosomes in the cere-
bro-spinal fluid and in the blood of five cases of the African sleeping sickness.
The Eoyal Society Commission (Bruce and Nabarro) demonstrated the great
frequency of the parasites in the cerebro-spinal fluid and in the blood in sleep-
ing sickness, and suggested that it was a sort of human tsetze fly infection.
Distribution". — For many years it had been kno-wTi that the West African
natives were subject to a remarkable malady known as the lethargy or sleeping
sickness. It was also met with among the slaves imported into America. The
demonstration of the association of the trypanosomes with the terrible sleeping
sickness has been the most important recent " find " in tropical medicine. The
disease prevails in Gambia, Sierra Leone, and Liberia, and is spreading rapidly
in the Congo basin, Uganda, and Ehodesia. The recent opening up of equa-
torial Africa has led to intercommunication between the different districts
which were formerly isolated, and the seriousness of the disease may be appre-
ciated from the fact that within three years after its introduction 100,000
negroes died of it in Uganda. The parasites may be present in the blood for
a long time, at least without causing any symptoms. Bruce found them in
23 out of 80 apparently healthy natives, and Button, Todd, and Christy in
103 out of 1,172 persons examined.
The disease is not confuied to negroes, and several Europeans have been
attacked. Persons particularly prone are those who live on the wooded shores
of the lakes and rivers, such as fishermen and canoe men.
The parasite is introduced by the bite of a fly, the Glossina palpalis, and
where this insect exists the disease is liable to prevail. The fly lives on the
bushes on the lake shores or river banks, and feeds on the blood of crocodiles,
antelopes, etc. It is possible that the trypanosomes undergo a development
in the body of the fly. Koch states that the disease may be conveyed to women
in coition.
Symptoms. — There is stated to be a long latent period. The Uganda Com-
missioners divide the course of the disease into three stages: first, of fever
with rapid pulse, dulling of the mind, and loss of weight; secondly, the stage
of tremors in which the gait becomes shuffling, the speech slow, and there are
tremors of the tongue and of the hands and feet; lastly, a stage in which the
patient becomes lethargic with low temperature and presents the typical picture
of the dreaded sleeping sickness. The parasites are found in the cerebro-spinal
fluid, less constantly in the blood. In the early stages the glands of the neck
are involved, and Todd and Button recommend puncture of these glands for
the purpose, of diagnosis. Beath is usually caused by some intercurrent infec-
tion, as purulent meningitis or suppuration of the lymph glands. The dura-
tion is seldom longer than eighteen months. Europeans are not often attacked.
To stay the ravages and prevent the spread of the disease will tax the energies
of the nations interested in the settlement of tropical Africa. The hope
appears to be in the extermination of the animals upon which the Glossina
palpalis feeds (among which Koch holds the crocodile to be the most impor-
tant), just as the killing off of the big game in other parts of iVfrica has
saved the cattle from the ravages of the tsetze fly.
DISEASES DUE TO PROTOZOA. 9
Wolferstan Thomas and Breinl introduced the atoxyl treatment, and
Boyce recommends the subsequent use of bichloride of mercury. Koch's re-
port on the atoxyl treatment is most encouraging; 0.5 gramme is injected
on two successive days, and repeated at intervals of ten days. A few cases
have been cured. As prophylactic measures, segregation and prohibition of
immigration from infected areas should be carried out. The work of Laveran
and Mesnil, recently translated and edited by Nabarro, is the standard author-
ity on the disease.
IV. TROPICAL SPLENOMEGALY— Tropical Cachexia.
(Piroplasmosis — Dum-Dum Fever — Kala-Azar.)
Definition. — A chronic disease of tropical and sub-tropical countries,
characterized by enlarged spleen, anaemia, irregularly remittent fever, asso-
ciated with the presence of a protozoon parasite of the piroplasma type.
In 1900 Leishman discovered the parasites in the spleen. Cunningham
had described similar bodies in the Delhi boil. In 1903 Donovan's inde-
pendent observations stimulated active work on the subject, and the careful
studies of Eogers, Christophers, Philips, and Bentley have established the
clinical and anatomical identity of one form of tropical cachexial fever.
Musgrave and Woolley have shown that in the Philippines there is a form
of tropical splenomegaly not associated with the Leishman-Donovan body.
Distribution. — The disease is widely prevalent and almost uniformly fatal
in India, Assam, Ceylon, China, and Egypt. Europeans are rarely attacked.
The Parasite. — Most abundant in the spleen, it has been found also in
the bone-marrow, the mesenteric glands, the liver, in the intestinal ulcers, but
not in the circulating blood. Seen in smears of the spleen juice stained by
Eomanowsky's method, there are oat-shaped, oval and circular bodies, with a
spherical nucleus close against the capsule, and a short, rod-like body on the
opposite side. Two of these bodies may be closely applied to each other, and
groups of them, from ten to fifty, may be arranged in a rosette. Eogers has
cultivated a trypanosoma-like body from these forms, and Patton has traced
its extra-corporeal development in the bed-bug.
Symptoms. — The following succinct description is given by Leishman:
" Splenic and hepatic enlargement — the former being apparently constant,
while the latter is common but not invariable. A peculiar earthy pallor of
the skin, and, in the advanced stages, an intense degree of emaciation and
muscular atrophy. A long-continued, irregularly remittent fever, of no defi-
nite type, lasting frequently for many months, with or without remissions.
Hsemorrhages, such as epistaxis, bleeding from the gums, subcutaneous haem-
orrhages or purpuric eruptions. Transitory cedemas of various regions or of
the limbs." The anaemia is not excessive, rarely below 2,000,000 per c.mm.,
with a marked leucopenia and a relative increase in the lymphocytes and large
mononuclears. The diagnosis rests upon the detection of the parasites in the
blood obtained by puncture from the spleen or liver, preferably the latter.
In a few cases the disease runs an acute course — from four to five months,
and toward the end the parasites are found in the peripheral blood. The
disease is very fully considered in Eogers' work " On Tropical Diseases."
3
10 DISEASES DUE TO ANIMAL PARASITES.
Prophylaxis. — Leonard Eogers and Price have shown that Jcala-azar can
be eradicated from infected Coolie lines in Assam by segregation, and this
points to the measures which are likely to be successful in India and Africa.
Treatment. — While quinine is not a specific, as in malaria, it seems to
reduce the fever. Iron, arsenic, and tonics are helpful in the anemia. The
atoxyl treatment may be tried.
V. MALARIAL FEVER.
Definition. — An infectious disease characterized by: (a) paroxysms of
intermittent fever of quotidian, tertian, or quartan type; (&) a continued
fever with marked remissions; (c) certain pernicious, rapidly fatal forms;
and (d) a chronic cachexia, with anaemia and an enlarged spleen.
With the disease are invariably associated the hamocytozoa described by
Laveran, which are transmitted to man by the bite of the mosquito.
Etiology. — (1) Geographical Distribution. — In Europe, southern Eus-
sia and certain parts of Italy are now the chief seats of the disease. It is rare
in Germany, France, and England, and the foci of epidemics are becoming
yearly more restricted. In the United States malaria has progressively dimin-
ished in extent and severity during the past fifty years. Erom New England,
where it once prevailed extensively, it has gradually disappeared, but there
has of late years been a slight return in some places. In the city of New York
the milder forms of the disease are not uncommon. In Philadelphia and along
the valleys of the Delaware and Schuylkill Elvers, formerly hot-beds of
malaria, the disease has become much restricted. In Baltimore a few cases
occur in the autumn, but a majority of the patients seeking relief are from
the outlying districts and one or two of the inlets of Chesapeake Bay.
Throughout the Southern States there are many regions in which malaria
prevails ; but here, too, the disease has diminished in prevalence and intensity.
In the Northwestern States malaria is almost unknown. It is rare on the
Pacific coast. In the region of the Great Lakes malaria prevails only in the
Lake Erie and Lake St. Clair regions. The St. Lawrence basin remains free
from the disease.
In India malaria is very prevalent, particularly in the great river basins.
In Burma and Assam severe types are met with. In Africa the malarial fevers
form the great obstacle to European settlements on the coast and along the
river basins. The hlack-water or West African fever of the Gold Coast is a
very fatal type of malarial ha^moglobinuria. In the Canal Zone, Panama, in
1907 the incidence of the disease was reduced one-half compared with 1906.
(2) Season. — In the tropics there are minimal and maximal periods, the
former corresponding to the summer and winter, the latter to the spring and
autumn months. In temperate regions, like the central Atlantic States, there
are only a few cases in the spring, usually in the month of May, and a large
number of cases in September and October, and sometimes in November.
(3) The Parasite. — Parasites of the red blood-corpuscles — hsemocytozoa
— are very widespread throughout the animal series. They are met with in
the blood of frogs, fish, birds, and among mammals in monkeys, bats, cattle,
and man. In birds and in frogs the parasites appear to do no harm except
when present in very large numbers.
DISEASES DUE TO PROTOZOA. 11
In 1880 Laveran, a French army surgeon stationed at Algiers, noted in
the blood of patients with malarial fever pigmented bodies, which he regarded
as parasites, and as the cause of the disease, Richard, another French army
surgeon, confirmed these observations. In 1885 Marchiafava and Celli
described the parasites with great accuracy, and in the same year Golgi made
the all-important observation that the paroxysm of fever invariably coincided
with the sporulation or segmentation of a group of the parasites. In the fol-
lowing year (1886) Laveran's observations were brought before the profession
of the United States by Sternberg. Councilman and Abbott had already, in
the previous year, described the remarkable pigmented bodies in the red blood-
corpuscles in the blood-vessels of the brain in a fatal case, and in 1886 Coun-
cilman confirmed the observations of Laveran in clinical cases. Stimulated
by his work, I began studying the malarial cases in the Philadelphia Hospital,
and soon became convinced of the truth of Laveran's discovery, and was able
to confirm Golgi's statement as to the coincidence of the sporulation with the
paroxysm. The work was taken up actively in the United States by Walter
James, Dock, Koplik, Thayer, Hewetson, and others, and in a number of sub-
sequent communications I tried to emphasize the extraordinary clinical
importance of Laveran's discovery.*
Among British observers, Vandyke Carter alone, in India, seems to have
appreciated at an early date the profound significance of Laveran's work.
The next important observation was the discovery by Golgi that the para-
site of quartan malarial fever was different from the tertian. From this
time on the Italian observers took up the work with great energy, and in 1889
Marchiafava and Celli determined that the organism of the severer forms of
malarial fever differed from the parasite of the tertian and quartan varieties.
During the past ten years the work of observers in many lands has confirmed
these essential features, and has added greatly to our knowledge of the struc-
ture and modes of development of the parasites.
The next important step related to the question of the mode of infec-
tion. It had been suggested by King, of Washington, and others, that the
disease was transmitted by the mosquitoes. The important role played by
insects as an intermediate host had been shown in the case of the Texas
cattle fever, in which Theobald Smith demonstrated that the hgematozoa
developed in, and the disease was transmitted by, ticks; but it remained
for Manson to formulate in a clear and scientific way the theory of infec-
tion in malaria by the mosquito. Impressed with the truth of this, Ross
studied the problem in India, and showed that the parasites developed in
the bodies of the mosquitoes, demonstrating conclusively that the infection in
birds was transmitted by the mosquito. W. G, MacCallum suggested that
* The following references to work on malaria which has been done in connection with
my clinic, chiefly under the supervision of my colleague, Professor Thayer, may be of in-
terest : Philadelphia Medical Times, 1886 ; British Medical Journal, March, 1887 ; Medical
News, 1889, vol, i ; Johns Hopkins Hospital Bulletin, 1889 ; the first edition of my Text-
Book of Medicine, 1892; Thayer and Hewetson, Johns Hopkins Hospital Reports, 1895;
Thayer Lectures on Malarial Fever, 1897; W, G. MacCallum, Hsematozoa of Birds, Jour, of
Exp. Med., 1898 ; Opie, on the HaBmatozoa of Birds, 1898 ; Barker, on Fatal Cases of Malaria,
Johns Hopkins Hospital Reports, 1899: MacCallum, on the Significance of the Flagella,
Lancet, 1897; Thayer, Transactions American Medical Congress, vol. iv, 1900; Lazear,
Structure of the Malarial Parasites, Johns Hopkins Hospital Reports, 1902.
12 DISEASES DUE TO ANIMAL PARASITES.
the flagella were sexual elements, and observed the process of fertilization
by them. Studies by Grassi, Bastianelli and Bignami, and man} others, con-
firmed the observations of Eoss and demonstrated the fact that the malarial
parasites of human beings develop only in mosquitoes of the genus anopheles.
Then came the practical demonstration by Italian observers, and by the
interesting experiments on Manson, Jr., of the direct transmission of the
disease to man by the bite of infected mosquitoes. And lastly, as a practical
conclusion of the whole matter, the results of the antimalarial campaign in
Italy and of the remarkable experiments of Koch and his assistants have
shown that by protecting the individual from the bites of mosquitoes, by
exterminating the insect, or by carefully treating all patients so that no
opportunity may be offered for the parasite to enter the mosquito, malaria
may be eradicated from any locality.
General Morphology of the Parasite. — Belonging to the sporozoa, it has
received a, large number of names. The term Plasmodium, inapt though it
may be, must, according to the rules of zoological nomenclature, be applied
to the human parasite. There are three well-marked varieties of the para-
site, which exist in two separate phases or stages: (a) the parasite in man
who acts as the intermediate host, and in whom, in the cycle of its develop-
ment, it causes symptoms of malaria; and (&) an extracorporeal cycle, in
which it lives and develops in the body of the mosquito, which is its definitive
host.
I. The Parasite in Man. — (a) The Parasite of Tertian Fever (Plas-
modium vivax). — The earliest form seen in the red blood-corpuscle is round
or irregular in shape, about 2 ft in diameter and unpigmented. It corresponds
very much in appearance with the segments of the rosettes formed during the
chill. A few hours later the body has increased in size, is still ring-shaped,
and there is pigment in the form of fine grains. It has a relatively large
nuclear body, consisting of a well-defined, clear area, in part almost transpar-
ent, in part consisting of a milk-white substance, in which there lies a small,
deeply staining chromatin mass, as shown by Eomanowsk}'''s method of stain-
ing. At this period it usually shows active amoeboid movements, with tongue-
like protrusions. The pigment increases in amount and the corpuscle becomes
larger and paler, owing to a progressive diminution of its hsemoglobin. There
is a gradual growth of the parasite, which, toward the end of forty-eight
hours, occupies almost all of the swollen red corpuscle. It is now much
pigmented, and is in the stage of what is often called the full-grown parasite.
Between the fortieth and forty-eighth hours many of the parasites are seen
to have undergone the remarkable change known as segmentation, in which
the pigment becomes collected into a single mass or block, and the proto-
plasm divides into a series of from fifteen to twenty spores, often showing a
radial arrangement. Certain full-grown tertian parasites, however, do not
undergo segmentation. These forms, which are larger than the sporulating
bodies, and contain very actively dancing pigment granules, represent the
sexually differentiated form of the parasite — gametocytes.
(&) The Parasite of Quartan Fever {Plasmodium malarice). — The earliest
form is very like the tertian in appearance, but as it increases in size the
earlier granules are coarser and darker and the movement is not nearly so
marked. By the second day the parasite is still larger, rounded in shape^
DISEASES DUE TO PROTOZOA. 13
scarcely at all amoeboid, and the pigment is more often arranged at the periph-
ery of the parasite. The rim of protoplasm about it is often of a deep yel-
lowish-green color or of a dark brassy tint. On the third day the segment-
ing bodies become abundant, the pigment flowing in toward the centre of the
parasite in radial lines so as to give a star-shaped appearance. The parasites
finally break up into from six to twelve segments. Here also, as in the case
of the tertian parasite, some full-grown bodies persist without sporulating,
representing the gametocytes.
(c) The Parasite of the /Estivo- Autumnal Fever {Plasmodium, prcecox) is
considerably smaller than the other varieties ; at full development it is often
less than one half the size of a red blood-corpuscle. The pigment is much
scantier, often consisting of a few minute granules. At first only the earlier
stages of development, small, hyaline bodies, sometimes with one or two pig-
ment granules, are to be found in the peripheral circulation; the later stages
are ordinarily to be seen only in the blood of certain internal organs, the spleen
and bone marrow particularly. The corpuscles containing the parasites
become not infrequently shrunken, crenated, and brassy-colored. After the
process has existed for about a week, larger, refractive, crescentic, ovoid, and
round bodies, with central clumps of coarse pigment granules, begin to appear.
These bodies are characteristic of aestivo-autumnal fever. The crescentic and
ovoid forms are incapable of sporulation; they are analogous to the large,
full-grown, non-sporulating bodies of the tertian and quartan parasites which
have been mentioned above, and represent sexually differentiated forms —
gametocytes. Within the human host they are incapable of further develop-
ment, but upon the slide, or within the stomach of the normal intermediate
host, the mosquito, the male elements (micro-gametocytes) give rise to a num-
ber of long, actively motile flagella (micro-gametes) which break loose, pene-
trating and fecundating the female forms — macro-gametes (W. G-. Mac-
Callum). The fecundated female form enters into the stomach wall of the
intermediate host, the mosquito, where it undergoes a definite cycle of
existence.
II. The Parasite within the Body of the Mosquito. — The brilliant re-
searches of Eoss, followed by the work of Grassi, Bastianelli, Bignami,
Stephens, Christophers, and Daniels, have proved that a certain genus of
mosquito — anopheles — is not only the intermediate host of the malarial para-
site, but also the sole source of infection. In the present state of our knowl-
edge it would appear that all species of the genus anopheles may act as hosts
of the parasite. The more common genera of mosquito in temperate cli-
mates are culex and anopheles. The different species of culex form the great
majority of our ordinary house mosquitoes, and are apparently incapable of
acting as hosts of the malarial parasite. All malarial regions, however,
which have been investigated contain anopheles. Although this is appar-
ently a positive rule, anopheles may, however, be present without the exist-
ence of malaria under two circumstances: first, when the climate is too' cold
for the development of the malarial parasite ; and secondly, in a region which
has not yet been infected. So far as is known, the parasite exists only in the
mosquito and in man. It is apparently fair to state that regions in which
mosquitoes of the genus anopheles are present may become malarious during
the warm season.
14 DISEASES DUE TO ANIMAL PARASITES.
A large number of species of anopheles have been described. In Xorth
America, however, only four have been positively recognized: A. 'punctlpeiinis
(Say), A. maculipennis (Wied), A. crucians (Wied), A. argyritarsis (Desv.).
The commonest variety, and that which in all probability is most concerned in
the spread of the disease, is A. maculipennis, which is, also, the most impor-
tant agent in the spread of the disease on the Continent.
The palpi in the mature culex are extremely short, only to be seen on
careful observation at the base of the proboscis, while in the anopheles they
are nearly of equal length with the proboscis, so that on superficial observa-
tion the insect would appear to have three proboscides. The wings of the
common species of culex show no markings beyond the ordinary veins. The
wings of all the x4.merican species of anopheles show distinct mottling. The
culex, when sitting upon the wall or ceiling, holds its posterior pair of legs
turned up above its back, while the body lies nearly parallel to the wall. In
some instances, when it is full of blood, and sitting upon the ceiling, the body
may sag downward considerably. The anopheles, when sitting upon the wall
or ceiling, holds its posterior pair of legs commonly either against the wall
or hanging downward, though in some instances they may be lifted above the
back. The body, however, instead of lying parallel to the wall or ceiling,
protrudes at an angle of 45° or more. These simple points are sufficient to
permit the ready distinction of species by almost any individual.
The culex lays its eggs in sinks, tanks, cisterns, and any collection of
water about or in houses, while anopheles lays its eggs in small, shallow pud-
dles or slowly running streams, especially those in which certain forms of
algae exist. The culex is essentially a city mosquito, the anopheles a
country insect.
Evolution in the Body of the Mosquito. — When a mosquito of the genus
anopheles bites an individual whose blood contains sex-ripe forms (gameto-
cytes) of the malarial parasite, flagellation and fecundation of the female
element occurs within the stomach of the insect. The fecundated element
then penetrates the wall of the mosquito's stomach and begins a definite cycle
of development in the muscular coat. Two days after biting there begin to
appear small, round, refractive, granular bodies in the stomach wall of the
mosquito, which contain pigment granules clearly identical with those pre-
viously contained in the malarial parasite. These develop until at the end
of seven days they have reached a diameter of from 60 to 70 fi. At this
period they may be observed to show a delicate radial striation due to the
presence of great numbers of small sporoblasts. The mother oocyst (z5'gote)
then bursts, setting free into the body cavity of the mosquito an enormous
number of delicate spindle-shaped sporozoids. These accumulate in the cells
of the veneno-salivary glands of the mosquito, and, escaping into the ducts,
are inoculated with subsequent bites of the insect. These little spindle-shaped
sporozoids develop, after inoculation into the warm-blooded host, into fresh
young parasites. The sporozoid which has developed in the oocyst in the
stomach wall of the mosquito is then the equivalent of the spore resulting
from the asexual segmentation of the full-grown parasite in the circulation.
Either one, on entering a red blood-corpuscle, may give rise to the asexual
or sexual cycle. As a rule the first several generations of parasites in the
human body pursue the asexual cycle, the sexual forms developing later.
DISEASES DUE TO PROTOZOA. 15
These sexual forms, sterile while in the human host, serve as the means of
preserving the life of the parasite and spreading infection when the individual
is subjected to bites of anopheles.
Mr. Howard, of the Entomological Department at Washington, has issued
a very useful pamphlet on the varieties and the methods of identification of
the mosquito. In Africa the distribution of the forms has been studied by
Stephens, Christophers, and Daniels. To those interested in the subject,
Christophers' careful study of the Anatomy and Histology of the Adult
Female Mosquito (Report of Malaria Committee, Royal Society, No. IV)
will prove of great help. The Royal Society Reports (Malaria Committee)
and the Studies of the Liverpool School may be consulted for technical details
and for valuable information relating to tropical malaria.
Morbid Anatomy. — The changes result from the disintegration of the
red blood-corpuscles, accumulation of the pigment thereby formed, and
possibly the influence of toxic materials produced by the parasite. Cases
of simple malarial infection, the ague, are rarely fatal, and our knowledge
of the morbid anatomy of the disease is drawn from the pernicious malaria
or the chronic cachexia. Rupture of the enlarged spleen may occur spon-
taneously, but more commonly from trauma. A case of the kind was
admitted under my colleague, Halsted, in June, 1889, and Dock has reported
two cases. I have known fatal haemorrhage to follow the exploratory punc-
ture of an enlarged malarial spleen.
(1) Pernicious Malaeia. — The blood is hydremic and the serum may
even be tinged with haemoglobin. The red blood-corpuscles present the
endoglobular forms of the parasite and are in all stages of destruction.
The spleen is enlarged, often only moderately; thus, of two fatal cases
in my wards the spleens measured 13 X 8 cm. and 14 X 8 cm. respec-
tively. In a fresh infection, the spleen is usually very soft, and the pulp
lake-colored and turbid. The liver is swollen and turbid.
In some acute pernicious cases with choleraic symptoms, the capillaries
of the gastro-intestinal mucosa may be packed with parasites.
(2) Malarial Cachexia. — In fatal cases of chronic paludism death
occurs usually from anaemia or the haemorrhage associated with it.
The anaemia is profound, particularly if the patient has died of fever.
The spleen is greatly enlarged, and may weigh from seven to ten pounds.
The liver may be greatly enlarged, and presents to the naked eye a
grayish-brown or slate color, due to the large amount of pigment. In the
portal canals and beneath the capsule the connective tissue is impregnated
with melanin. The pigment is seen in the Kupffer's cells and the perivascu-
lar tissue.
The kidneys may be enlarged and present a grayish-red color, or areas of
pigmentation may be seen. The peritonaeum is usually of a deep slate color.
The mucous membrane of the stomach and intestines may have the same hue,
due to the pigment in and about the blood-vessels. In some cases this is con-
fined to the lymph nodules of Peyer's patches, causing the shaven-beard
appearance.
(3) The Accidental and Late Lesions of Malarial Fever. — (a) The
Liver. — Paludal hepatitis plays a very important role in the history of
malaria, as described by French writers. Only those cases in which the his-
16 DISEASES DUE TO ANIMAL PARASITES.
tory of chronic malaria is definite, and in which the melanosis of both liver
and spleen coexist, should be regarded as of paludal origin.
(h) Pneumonia is believed by many authors to be common in malaria,
and even to depend directly upon the malarial poison, occurring either in
the acute or in the chronic forms of the disease. I have no personal knowledge
of such a special pneumonia.
(c) Nephritis. — Moderate albuminuria is a frequent occurrence, having
occurred in 46.4 per cent of the cases in my wards. Acute nephritis is rela-
tively frequent in aestivo-autumnal infections, having occurred in over 4.5
per cent of my cases. Chronic nephritis occasionally follows long-continued
or frequently repeated infections.
Clinical Forms of Malarial Fever. — (1) The Regularly Inteemittent
Fevees. — (a) Tertian fever; (6) quartan fever. These forms are charac-
terized by recurring paroxysms of what are knoAVQ as ague, in which, as a
rule, chill, fever, and sweat follow each other in orderly* sequence. The
stage of iiicubation is not definitely known; it probably varies much accord-
ing to the amount of the infectious material absorbed. Experimentally the
period of incubation varies from thirty-six hours to fifteen days, being a trifle
longer in quartan than in tertian infections. Attacks have been reported
within a very short time after the apparent exposure. On the other hand,
the ague may be, as is said, " in the system," and the patient may have a
paroxysm months after he has removed from a malarial region, though of
course this can not be the case unless he has had the disease when living there.
Description of the Paroxysm. — The patient generally knows he is going
to have a chill a few hours before its advent by unpleasant feelings and uneasy
sensations, sometimes by headache. The paroxysm is divided into three stages
— cold, hot, and sweating.
Cold Stage. — The onset is indicated by a feeling of lassitude and a desire
to yawn and stretch, by headache, uneasy sensations in the epigastrium, some-
times by nausea and vomiting. Even before the chill begins the thermometer
indicates some rise in temperature. Gradually the patient begins to shiver,
the face looks cold, and in the fully developed rigor the whole body shakes, the
teeth chatter, and the movements may often be violent enough to shake the
bed. I^ot only does the patient look cold and blue, but a surface ther-
mometer will indicate a reduction of the skin temperature. On the other
hand, the axillary or rectal temperature may, during the chill, be greatly
increased, and, as shown in the chart, the fever may rise meanwhile even to
105° or 106°. Of symptoms associated with the chill, nausea and vomiting
are common. There may be intense headache. The pulse is quick, small,
and hard. The urine is increased in quantity. The chill lasts for a variable
time, from ten or twelve minutes to an hour, or even longer.
The hot stage is ushered in by transient flushes of heat; gradually the
coldness of the surface disappears and the skin becomes intensely hot. The
contrast in the patient's appearance is striking: the face is flushed, the
hands are congested, the skin is reddened, the pulse is full and bounding, the
heart's action is forcible, and the patient may complain of a throbbing head-
ache. There may be active delirium. One of my patients in this stage
jumped through a ward window and sustained fatal injuries. The rectal
temperature may not increase much during this stage; in fact, by the termi"
DISEASES DUE TO PROTOZOA. 17
nation of the chill the fever may have reached its maximum. The duration
of the hot stage varies from half an hour to three or four hours. The patient
is intensely thirsty and drinks eagerly of cold water.
Sweating Stage. — Beads of perspiration appear upon the face and grad-
ually the entire body is bathed in a copious sweat. The uncomfortable feel-
ing associated with the fever disappears, the headache is relieved, and within
an hour or two the paroxysm is over and the patient usually sinks into a
refreshing sleep. The sweating varies much. It may be drenching in char-
acter or it may be slight.
Chart la is from a case of double tertian infection with resulting quotidian
paroxysms. Charts I& and Ic give temperature curves in aestivo-autumnal
forms. Chart Id shows a quartan ague.
The total duration of the paroxysm averages from ten to twelve hours, but
may be shorter. Variations in the paroxysm are common. Thus the patient
may, instead of a chill, experience only a slight feeling of coldness. The most
common variation is the occurrence of a hot stage alone, or with very slight
sweating. During the paroxysm the spleen is enlarged and the edge can usu-
ally be felt below the costal margin. In the interval or intermission of the
paroxysm the patient feels very well, and, unless the disease is unusually
severe, he is able to be up. Bronchitis is a common symptom. Herpes, usu-
ally labial, is almost as frequent in ague as in pneumonia.
Types of the Regularly Intermittent Fevers. — As has been stated in the
description of the parasites, two distinct types of the regularly intermit-
tent fevers have been separated. These are (a) tertian fever and (&)
quartan fever.
(a) Tertian Fever. — This type of fever depends upon the presence in the
blood of the tertian parasite, an organism which, as stated above, is usually
pi-esent in sharply defined groups, whose cycle of development lasts approx-
imately forty-eight hours, segmentation occurring every third day. In
infections with one group of the tertian parasite the paroxysms occur syn-
chronously with segmentation at remarkably regular intervals of about forty-
eight hours, every third day — hence the name tertian. Very commonly,
however, there may be two groups of parasites which reach maturity on alter-
nate days, resulting thus in daily (quotidian) paroxysms — douMe tertian
infection. Quotidian fever, depending upon double tertian infection, is the
most frequent type in the acute intermittent fevers in this latitude.
(&) Quartan Fever. — This type of fever depends upon infection with the
quartan parasite, an organism which occurs in well-defined groups, whose
cycle of existence lasts about seventy-two hours. In infection with one group
of parasites the paroxysm occurs every fourth day; hence the term qu/irtan.
At times, however, two groups of the parasites may be present; under these
circumstances paroxysms occur on two successive days, with a day of inter-
mission following. In infection with three groups of parasites there are
daily paroxysms.
Thus a quotidian intermittent fever may be due to infection with either
the tertian or quartan parasites.
Course of the Disease. — After a few paroxysms, or after the disease has
persisted for ten days or two "weeks, the patient may get well without any
special medication, I have repeatedly known the chills to stop spontane-
18
DISEASES DUE TO ANIMAL PARASITES.
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The case was treated for
AL Infection. — Remittent Fever.
a week as one of typhoid fever.
DISEASES DUE TO PROTOZOA.
19
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Chart Ic. — ^stivo-Autumnal Fever. — Quotidian Paroxysms.
July 19 20 21 22 23 21 |
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Chart Id. — Quartan Fever.
20 DISEASES DUE TO ANIMAL PARASITES.
ously. Eelapses are common. The infection may persist for years, and an
attack may follow an accident^, an acute fever, or a surgical operation. A rest-
ing stage of the parasite has been suggested in explanation of these long inter-
vals. Persistence of the fever leads to aneemia and haematogenous jaundice,
owing to the destruction of the blood-disks. Ultimately the condition may
become chronic — malarial cachexia.
(2) The more Irregular, Eemittent, or Continued Fevers. — 2Estivo-
autumnal Fever. — This type of fever occurs in temperate climates, chiefly
in the later summer and autumn ; hence the term given to it by Marchiaf ava
and Celli, cestivo-autumnal fever. The severer forms of it prevail in the
Southern States and in tropical countries.
This type of fever is associated with the presence in the blood of the
Eestivo-autumnal parasite, an organism the length of whose cycle of develop-
ment, ordinarily about forty-eight hours, is probably subject to considerable
variations, while the existence of multiple groups of the parasite, or the
absence of arrangement into definite groups, is not infrequent.
The symptoms are therefore, as might be expected, often irregular. In
some instances there may be regular intermittent fever occurring at uncer-
tain intervals of from twenty-four to forty-eight hours, or even more. In
the cases with longer remissions the paroxysms are longer. Some of the
quotidian intermittent cases may closely resemble the quotidian fever depend-
ing upon double tertian or triple quartan infection. Commonly, however,
the paroxysms show material differences; their length averages over twenty
hours, instead of from ten or twelve; the onset occurs often without chills
and even without chilly sensations. The rise in temperature is frequently
gradual and slow, instead of sudden, while the fall may occur by lysis instead
of by crisis. There may be a marked tendency toward anticipation in the
paroxysms, while frequently, from the anticipation of one paroxysm or the
retardation of another, more or less continuous fever may result. Some-
times there is continuous fever without sharp paroxysms. In these cases of
continuous and remittent fever the patient, seen fairly early in the disease,
has a flushed face and looks ill. The tongue is furred, the pulse is full
and bounding, but rarely dicrotic. The temperature may range from 103°
to 103°, or is in some instances higher. The general appearance of the
patient is strongly suggestive of typhoid fever — a suggestion still further
borne out by the existence of acute splenic enlargement of moderate grade.
As in intermittent fever, an initial bronchitis may be present. The course
of these cases is variable. The fever may be continuous, with remissions
more or less marked; definite paroxysms with or without chills may occur,
in which the temperature rises to 105° or 106°. Intestinal symptoms are
usually absent. A slight hsematogenous jaundice may arise early. Delirium
of a mild type may occur. The cases vary very greatly in severity. In
some the fever subsides at the end of the week, and the practitioner is in
doubt whether he has had to do with a mild typhoid or a simple febricula.
In other instances the fever persists for from ten days to two weeks; there
are marked remissions, perhaps chills, with a furred tongue and low delir-
ium. Jaundice is not infrequent. These are the cases to which the terms
hilious remittent and typho-malarial fevers are applied. In other instances
the symptoms become grave and assume the character of the pernicious type.
DISEASES DUE TO PROTOZOA. 21
It is in this form of malarial fever that so much confusion still exists. The
similarity of the cases to typhoid fever is most striking, more particularly the
appearance of the facies; the patient looks very ill. The cases occur, too,
in the autumn, at the very time when typhoid fever occurs. The fever yields,
as a rule, promptly to quinine, though here and there cases are met with —
rarely indeed in my experience — which are refractory. It is just in this group
that the observations of Laveran will be found of the greatest value. Several
of the charts in Thayer and Hewetson's report show how closely, in some
instances, the disease may simulate typhoid fever.
The diagnosis of malarial remittent fever may be definitely made by
the examination of the blood. The small, actively motile, hyaline forms
of the sestivo-autumnal parasite are to be found, while, if the case has lasted
over a week, the larger crescentic and ovoid bodies are often seen. In many
cases here we are at first unable to distinguish between typhoid and contin-
ued malarial fever without a blood examination. A more widespread use of
this means of diagnosis will enable us to bring some order out of the confu-
sion which exists in the classification of the fevers of the Southern States. At
present the following febrile affections are recognized by various physicians as
occurring in the subtropical regions of America: (a) Typhoid fever; (h)
typho-malarial fever — a typhoid modified by malarial infection, or the result
of a combined infection; (c) the malarial remittent fever; and (d) continued
thermic fever (Guiteras). In these various forms, all of which may be
characterized by a continued pyrexia with remissions or with chills and sweats
(for we must remember that chills and sweats in typhoid fever are by no
means rare), the blood examination will enable us to discover those which
depend upon the malarial poison. In many of these cases of continued or
remittent fever careful inquiry will show that at the beginning the patient
had several intermittent paroxysms. In Baltimore not many of the pro-
tracted and severe cases have occurred, and I am inclined to think that future
observations will show that, apart from the thermic fever, there are only two
forms of these continued fevers in the South — the one due to the typhoid and
the other to the malarial infection. The typhoid fever of Philadelphia and
Baltimore presents no essential difference from the disease as it occurs in
Montreal, a city practically free from malaria. Dock has shown conclusively
that cases diagnosed in Texas as continued malarial fever were really true
typhoid. The Widal reaction is now an important aid in diagnosis.
Pernicious Malarial Fever. — This is fortunately rare in temperate cli-
mates, and the number of cases which now occur, for example, in Philadelphia
and Baltimore, is very much less than it was thirty or forty years ago. Per-
nicious fever is always associated with the sestivo-autumnal parasite. The
following are the- most important types :
(a) The comatose form, in which a patient is struck down with symp-
toms of the most intense cerebral disturbance, either acute delirium or,
more frequently, a rapidly developing coma. A chill may or may not pre-
cede the attack. The fever is usually high, and the skin hot and dry. The
unconsciousness may persist for from twelve to twenty-four hours, or the
patient may sink and die. After regaining consciousness a second attack
may come on and prove fatal. In these instances, as has been stated, the
special localization of the infection is in the brain, where actual thrombi
22 DISEASES DUE TO ANIMAL PARASITES.
of parasites with marked secondary changes in the surrounding tissues have
been found.
(b) Algid Form. — In this, the attack sets in usually with gastric symp-
toms; there are vomiting, intense prostration, and feebleness out of all
proportion to the local disturbance. The patient complains of feeling cold,
although there may be no actual chill. The temperature may be normal,
or even subnormal; consciousness may be retained. The pulse is feeble and
small, and the respirations are increased. There may be most severe diar-
rhoea, the attack assuming a choleriform nature. The urine is often dimin-
ished, or even suppressed. This condition may persist with slight exacerba-
tions of fever for several days and the patient may die in a condition of
profound asthenia. This is essentially the same as described as the asthenic
or adynamic form of the disease. In the cases with vomiting and diarrhoea,
Marchiafava has shown that the gastro-intestinal mucosa is often the seat of
a special invasion by the parasites, actual thrombosis of the small vessels with
superficial ulceration and necrosis occurring. Similar lesions were found by
Barker in the gastro-intestinal tract of a case from my wards.
(c) Hcemorrliagic Forms — Black-water Fever — Hsemoglobinuric Fever —
Malarial Hemoglobinuria. — In temperate regions these forms are rare; in
the tropics they are common. In the Southern States there are many dis-
tricts in which there is endemic hgemoglobinuria, believed to be of malarial
origin, while in parts of Africa there is the much-disputed malady known as
black-water fever. There seems to be no essential difference between the
malarial hasmoglobinuria of the Southern States and the African black-water
fever. As described by Stephens and Christophers (Eeport of Malaria Com-
mittee, Fifth Series), for two or three days the patient has a rise of tem-
perature, and if the blood is examined before the black-water the parasites are
almost invariably present. If examined after the administration of quinine
parasites are absent from the blood. These authors believe that there is a
causal connection between the quinine and the black-water. It is impossible
to say why quinine at one time can produce black-water, and at another, even
a few hours or days later, it can not. Stephens' study (Thompson-Yates and
Johnston Laboratory Eeports, 1903) gives the distribution of black-water
fever in the Southern States, in Central America, in Italy, and in Africa.
He gives a careful analysis of 95 cases. Malarial parasites were present in
95.6 per cent of the cases before the onset, and on the day of the appearance
of the black-water in 61.9 per cent. There is no question as to the malarial
nature of the disease, but whether there is a special malarial parasite is not
yet settled. There is little evidence to show that the malarial hgemoglobinuria
of the Southern States is due to quinine (Thayer). In most instances where
the disease has been carefully studied, the paroxysms have occurred in indi-
viduals who have been subject to frequently repeated attacks of malaria and
have been reduced to a more or less cachectic condition. Only 8 cases occurred
among the Isthmian Canal employees in 1907. Brem, Herrick, and the other
workers on the Isthmus have not settled the relationship to the malarial
attacks. They rather favour the view of some special character of the organ-
ism. They do not think that quinine is an important factor; on the other
hand, they find that intra-muscular injections of quinine are almost a specific,
10 grains every four hours for the first 48 hours.
DISEASES DUE TO PROTOZOA. 23
Malarial Cachexia. — The general symptoms are those of secondary anaemia
— breathlessness on exertion, oedema of the ankles, haemorrhages, particularly
into the retina. Occasionally the bleeding is severe, and I have twice known
fatal haematemesis to occur in association with the enlarged spleen. The fever
is variable. The temperature may be low for days, not going above 99.5°.
In other instances there may be irregular fever, and the temperature rises
gradually to 102.5° or 103°.
With careful treatment the outlook is good, and a majority of cases Re-
cover. The spleen is gradually reduced in size, but it may take several months,
or, indeed, in some instances several years, before the ague-cake entirely
disappears.
Earer Complications. — Paraplegia may be due to a peripheral neuritis
or to changes in the cord, and hemiplegia may occur in the pernicious comatose
form, or occasionally at the very height of a paroxysm. Acute ataxia has
been described, and there are remarkable cases with the symptoms of dissem-
inated sclerosis (Spiller). Multiple gangrene may occur, as in an instance
reported by me, in which a patient with sestivo-autumnal infection presented
many areas on the skin. Orchitis has been described by Charvot in Algiers
and Fedeli in Eome.
Prophylaxis. — In the discovery of Laveran there lay the promise of bene-
fits more potent than any gift science had ever ofEered to mankind — viz., the
possibility of the extermination of malaria. By the persistent missionary
efforts of Boss this promise has reached the stage of practical fulfilment, and
one of the greatest scourges of the race is now at our command. The story
of the Canal Zone, Panama, under Colonel Gorgas is a triumph of the appli-
cation of scientific methods. Between 1881 and 1904 among the employees
of the French Canal Company (a maximum in 1887 of 17,885, of whom
15,726 were negroes) the monthly mortality ranged from 60 to 80, and on
seven occasions was above 100, once reaching the enormous figure of 176.97
per 1,000. With the measures given below the mortality has fallen to that
of temperate regions. For 1907 the death rate among white employees
(10,709) was 16.71 per 1,000, among the negroes (28,634) 33.28 per 1,000.
In May, 1908, the mortality among 44,816 employees had fallen to the remark-
ably low figure of 10.44 per 1,000 !
The measures of prophylaxis are in the main three : ( 1 ) The rigid protec-
tion of houses against mosquitoes by screens and the use of mosquito nets. The
reports of the Italian Society for the Study of Malaria upon their efforts to
protect the workers on the railways, as well as the work of Eoss at Ismailia,
show how extraordinary are the results of these simple measures. The protec-
tion of the sleeper at night is one of the most essential measures. (2) An
earnest warfare against the mosquito on the part of sanitary authorities. In-
struction should be furnished to the people upon the habits and life history of
the insect, and of its relation to the disease. Pools, ponds, and marshy districts
should be drained, and in the malaria season petroleum should be used freely,
as it prevents the development of the larvae. Every case of malaria should be
regarded as a centre of infection, and in a systematic warfare against the
disease should be reported to the health authorities. In the tropics, segre-
gation of Europeans may do much to lessen the chances of infection. (3)
Lastly, every case should receive thorough and prolonged treatment with
24 DISEASES DUE TO ANIMAL PARASITES.
quinine. There is far too much carelessness on this point in the profes-
sion. Malarial infection is a difficult one to eradicate. Quinine is the only
known drug which is an effective parasiticide. Patients should be told to
resume the treatment in the spring and autumn for several years after the
primary infection. In very malarial districts, as many persons harbor the
parasites, who do not show any (or at the most very few) signs, a systematic
treatment with quinine should be instituted, particularly of the young children.
Diagnosis. — The endemic index of a country may be determined by the
" parasite rate " or by the " spleen rate." It is best sought for in children
in whom, as is well known, the infection may occur without much disturb-
ance of the health. To determine the index by examining the blood for the
parasites is a laborious and almost impossible task; on the other hand, as
the work of Eoss in Greece and Mauritius has shown, the index may be readily
gauged by an examination of the spleen. Thus, in the last-named island, of
31,022 children, 34.1 per cent had enlarged spleen.
The individual forms of malarial infection are readily recognized, but it
requires a long and careful training to become an expert in blood examination.
Great progress has been made in the past twenty years, and a diagnosis of
malaria is no longer a refuge for our ignorance. One lesson it is hard for
the practitioner to learn — namely, that an intermittent fever which resists
quinine is not malarial.
The malarial poison is supposed to influence many affections in a remark-
able way, giving to them a paroxysmal character. A whole series of minor
ailments and some more severe ones, such as neuralgia, are attributed to
certain occult effects of paludism. The more closely such cases are investi-
gated the less definite appears the connection with malaria.
Treatment. — As a rule, anopheles are more likely to bite after sun-
down, so that in regions in which the disease prevails extensively mosquito
netting should be used. Persons going to a malarial region should take about
10 grains of quinine daily, though Sezary found that 2 grains three times a
day was a sufficient protection against the disease. During the paroxysm the
patient should, in the cold stage, be wrapped in blankets and given hot drinks.
The reactionary fever is rarely dangerous even if it reaches a high grade. The
body may, however, be sponged. In quinine we possess a specific remedy
against malarial infection. Experiment has shown that the parasites are most
easily destroyed by quinine at the stage when they are free in the circulation
— ^that is, during and just after segmentation. While in most instances the
parasites of the regularly intermittent fevers may be destroyed, even in the
intra-corpuscular stage, in aestivo-autumnal fever this is much more difficult.
It should, then, be our object, if we wish to most effectually eradicate the
infection, to have as much quinine in circulation at the time of the paroxysm
and shortly before as is possible, for this is the period at which segmentation
occurs. In the regularly intermittent fevers from 10 to 30 grains in divided
doses throughout the day will in many instances prevent any fresh paroxysms.
If the patient comes under observation shortly before an expected paroxysm,
the administration of a good dose of quinine just before its onset may be
advisable to obtain a maximum effect upon that group of parasites. The
quinine will not prevent the paroxysm, but will destroy the greater part of
the group of organisms and prevent its further recurrence. It is safer to give
DISEASES DUE TO PARASITIC INFUSORIA. 25
at least 20 to 30 grains daily for the first three days, and then to continue
the remedy in smaller doses for the next two or three weeks. In gestivo-
autumnal fever larger doses may be necessary, though in relatively few in-
stances is it necessary to give more than 30 to 40 grains in the twenty-four
hours.
The quinine should be ordered in solution or in capsules. The pijls
and compressed tablets are more uncertain, as they may not be dissolved.
A question of interest is the efficient dose of quinine necessary to cure
the disease. I have a number of charts showing that grain doses three times
a day will in many cases prevent the paroxysm, but not always with the cer-
tainty of the larger doses. In cases of aestivo-autumnal fever with pernicious
symptoms it is necessary to get the system under the influence of quinine as
rapidly as possible. In these instances the drug should be administered hypo-
dermically as the dihydrochlorate in 15 to 20 grain doses, every two or three
hours. The muriate of quinine and urea is also a good form in which to
administer the drug hypodermically ; 10, 15, or 20 grain doses may be neces-
sary. In the most severe instances some observers advise the intravenous
administration of quinine, for which the very soluble bimuriate is well
adapted. Fifteen grains with a grain of sodium chloride may be injected in
about 2 drachms of distilled water. For extreme restlessness in these cases
opium is indicated, and cardiac stimulants, such as alcohol and strychnine,
are necessary. If in the comatose form the internal temperature is raised,
the patient should be put in a bath and doused with cold water. For malarial
anaemia, iron and arsenic are indicated.
An interesting question is much discussed, whether quinine does not cause
or at any rate aggravate the hasmoglobinuria. We have not yet seen a case in
which this condition has occurred as a result of the use of the drug, and Bas-
tianelli states that it is not seen in the Eoman malarial fevers. He recom-
mends that in any case of hsemoglobinuria if the blood shows parasites
quinine should be administered freely. In the post-malarial forms quinine
aggravates the attack. In an active malarial infection the patient runs less
risk with the quinine.
B. DISEASES DUE TO PARASITIC INFUSORIA.
Several flagellates are parasitic in man. The Trichomonas vaginalis,
which measures 15 /a to 25 /x in length, and has four flagella, which are as
long as or longer than the body, is by no means uncommon in the acid vaginal
mucus.
The Trichomonas or C ercomonas hominis lives in the intestines, and is
met with in the stools under all sorts of conditions. Freund from Dock's
clinic has reported a series of cases which show that the parasite may cause
acute and chronic diarrhoea with severe abdominal pain, and anatomically an
acute enteritis. In one of Dock's cases the parasites were associated with a
ha3mojrhagic cystitis without bacteria.
The Lamhlia intestinalis is another intestinal monad, larger than the
common trichomonas. Flagellates have also been found in the expectoration
26 DISEASES DUE TO ANIMAL PARASITES.
in cases of gangrene of the lung and of bronchiectasis, and in the exudate
of pleurisy.
The Balantidium coli, oval in form, 70 [x to 100 fi long and 50 /x to 70 /*
broad, may be pathogenic. It is common in pigs, and has been known to
produce an epidemic dysentery in apes (Harlow Brooks). The pathological
significance of this parasite has been much discussed of late, particularly by
Strong and Musgrave, Klimenko and Arkanazy. It has not only been found
in the stools and on the mucous membrane of the intestine, but the parasites
have occurred in the mucosa itself and in the submucosa. Apparently they
do not extend beyond the wall of the bowel.
C. DISEASES DUE TO FLUKES.-DISTOMIASIS.
The following are important clinical forms :
1. Pulmonary Distomiasis ; Parasitic Haemoptysis. — Paragonimus (Dis-
toma) Westermanii, the Asiatic lung or bronchial fluke, is from 8 to 16 mm.
in length by 4 to 8 mm. broad, and of a pinkish or reddish-brown color.
It is found extensively in China and Japan and Formosa, and cases are
occasionally imported into Europe and America. Stiles states that an im-
ported case has been found in Portland, Oregon. It has been found in the
United States in the cat, in the dog, and in the hog. One instance of pulmo-
nary distomiasis has been reported caused by the giant liver fluke.
Clinically the disease, as described by Manson and Einger, is characterized
by a chronic cough, with rusty-brown sputum, and occasional attacks of
haemoptysis, usually trifling, but sometimes very severe. The ova, which are
abundant in the sputum, are oval, smooth, and measure from 80 /x to 100 /* in
length by 40 /a to 60 /a in breadth. The parasites may affect other organs —
the liver and the brain.
2. Hepatic Distomiasis. — Five species of liver flukes of the family
Fasciolidse are known to occur in man. More specifically these are : ( 1 ) The
common liver fluke — Fasciola hepatica — which is a very common parasite in
the ruminants; (2) The lancet fluke — dicrocoelium (Distoma) lanceatum;
(3) Opisthorchis (Distoma) felineus, which is found in Prussia and Siberia,
and by Ward in cats in Nebraska ; (4) Opisthorchis noverca — Distomum con-
junctum — the Indian liver fluke described in man by McConnell; (5) Opis-
thorchis {Distoma) sinensis, which is by far the most important of the liver
flukes and occurs extensively in Japan, China, and India. It is 10 to 20 mm.
long by 2 to 5 mm. broad. The eggs are oval, 27 fi to SO fi by 15 ju. to 17 fi,
dark brown, with sharply defined operculum. A number of imported cases
have been found in Canada and the United States. White found 18 cases in
San Francisco.
The symptoms of hepatic distomiasis are best described in connection with
this latter form. The following account is abstracted from Wallace Taylor.
Young children are the chief sufferers. Many members of a family are usu-
ally affected. In some villages a large proportion of the inhabitants are
attacked. Among important symptoms are an irregular, intermittent diar-
rhoea; at first there may or may not be blood. The liver gradually enlarges.
DISEASES DUE TO FLUKES— DISTOMIASIS. 27
There may be pain and an intermittent jaundice. There is not much fever.
After lasting for two or three years dropsy comes on, anasarca and ascites.
The patient is greatly reduced by the diarrhoea and becomes very anaemic.
Even then transient recovery may take place, but as a rule there is a recur-
rence, and the patient dies after many years of illness. The ova of the para-
site are readily found in the stools.
3. Intestinal Distomiasis. — In India the Fasciolopsis (Distoma) BusMi
has been found in a number of cases in the small intestines. The Mesogoni-
mus heterophyes has been found in Egypt and Japan.
The Asiatic Amphistome — Gastrodiscus (Ampliistoma) liominis — a not
uncommon parasite in India — is easily recognized by its large posterior sucker.
4. Haemic Distomiasis; Bilharziosis. — One of the most important of para-
sitic diseases, caused by the blood fluke, Scliistosom.um hcematobium or Bil-
harzia licematohia. Endemic hgematuria has been known for many years,
particularly in Egypt, where in 1851 Bilharz discovered the parasite of the
disease. It prevails in South and North Africa, particularly the latter, in
Arabia, Persia, and the west coast of India. Imported cases are not very
uncommon in Europe, and an occasional instance is met with in the United
States. In Lower Egypt it is met with in one third of all the autopsies.
An Asiatic blood fluke, Schistosomum japonicum, has recently been discov-
ered which differs in small details from the African variety.
The parasite is singular among flukes as having the sexes separate, and
the male usually carries the female in a gynsecophorous canal. The mode of
entrance into the body is unknown, whether by the mouth, the urethra, or
through the skin. The eggs are very characteristic, oval in shape, 0.16 mm. by
0.06 mm., and one end has a terminal spine. The eggs hatch in water, but the
further development of the free-swimming embryos has not been followed.
Taken into the body, possibly with water or on cresses, it reaches the portal
veins, in which the worms are most commonly found, usually young speci-
mens and uncoupled. The males bearing the females creep to various parts,
particularly the bladder and rectum. The eggs are laid in the tissues, but
wander, like other sharp foreign bodies, and escape with the urine and faeces.
A majority of them remain in the tissues and cause irritation, fibroid changes,
and papillomata in the bladder and rectum. Collecting in the bladder as
foreign bodies they form the nuclei of calculi.
Symptoms. — As is so often the ease with animal parasites, they may
cause no inconvenience. Irritability of the bladder, dull pain in the peri-
nseum, and haematuria are the most frequent symptoms. A chronic cystitis
follows when the walls of the bladder are much thickened by the irritation
caused by the ova. The angemia caused by the haemorrhage is slight in com-
parison with that of ankylostomiasis. When the rectum is involved there are
straining and tenesmus, with the passage of mucus and blood ; in severe cases
large papillomata and a chronic ulcerative proctitis. There may be a chronic
vaginitis.
Of the complications, calculi in kidney and bladder are the most impor-
tant. Milton, Madden, and others of the Cairo School of Medicine have stud-
ied carefully the surgical aspects of the disease. Periurethral abscess and
perineal fistulse are very common in the chronic cases.
Few symptoms are caused by the presence of the parasites in the portal
28 DISEASES DUE TO ANIMAL PARASITES.
veins, but there may be an advanced cirrhosis of a Glissonian type due to ail
enormous thickening of the periportal tissues (Symmers). This author
has also reported an instance of the Bilharzia in the pulmonary blood in a case
of Bilharzial colitis, and the worms were found living in the pulmonary
circulation.
The diagnosis is readily made by finding the characteristic ova in the
bloody urine or in the blood and mucus from the rectum. The Bilharzia may
be present in the body for years without producing serious damage, and in
slight infections the symptoms may disappear (Sand with), particularly in
children.
Schistosoma Japonicum vel Cattoi. — In China and Japan and in the Phil-
ippines there is a disease characterized by cirrhosis of the liver, splenomegaly,
ascites, dysentery, progressive anaemia, and sometimes by localized epilepsy.
It occurs extensively in one district of Japan, and is known as the " Kata-
yama " disease. Woolley has met with it in the Philippines, and Catto in
China. The parasite lives in the vessels of the alimentary canal; the ova are
smaller than those of S. licematobium, and have not the characteristic spinous
ends.
Treatment. — ^We know of nothing which can kill the parasites in the
blood. Extract of male fern is recommended for the hsematuria. The
chronic cystitis and proctitis demand the usual measures for these disorders.
D. DISEASES CAUSED BY CESTODES.
{Tceniasis; Hydatid Disease.)
Man harbors the adult parasites in the small intestine, the larval forms
in the muscles and solid organs.
I. INTESTINAL CESTODES; TAPE- WORMS.
Taenia solium, or pork tape-worm. This is not a common form in
North America. It is much more frequent in parts of Europe and Asia.
When mature it is from 6 to 12 feet in length. The head is small, round,
not so large as the head of a pin, and provided with four sucking disks and
a double row of hooklets; hence it is called, in contradistinction to the
other form in man, the armed tape-worm. To the head succeeds a narrow,
thread-like neck, then the segments, or proglottides, as they are called. The
segments possess both male and female generative organs, and at about the
four-hundred-and-fiftieth they become mature and contain ripe ova. The
worm attains its full growth in from three to three and a half months, after
which time the segments are continuously shed and appear in the stools. The
segments are about 1 cm. in length and from 7 to 8 mm. in breadth. Pressed
between glass plates the uterus is seen as a median stem with about eight
to fourteen lateral branches. There are many thousands of ova in each ripe
segment, and each ovum consists of a firm shell, inside of which is a little
embryo, provided with six hooklets. The segments are continuously passed,
and if the ova are to attain further development they must be taken into the
stomach, either of a pig, or of man himself. The egg-shells are digested, the
DISEASES CAUSED BY CESTODES. 29
six-hooked embryos become free, and passing from the stomach reach various
parts of the body (the liver, muscles, brain, or eye), where they develop into
the larvae or cysticerci. A hog under these circumstances is said to be
measled, and the cysticerci are spoken of as measles or bladder worms.
Tmnia solium received its name because it was thought to exist as a soli-
tary parasite in the bowel, but two or three or even more worms may occijr.
Taenia saginata or mediocanellata — unarmed, fat, or beef tape-worm.
This is a longer and larger parasite than Tcenia solium. It is certainly the
common tape-worm of j^orth America. Of scores of specimens which I
have examined almost all were of this variety. According to Berenger-Feraud
it has spread rapidly in western Europe, owing probably to the importation
of beef and live-stock from the Mediterranean basin. It may attain a length
of 15 or 20 feet, or more. The head is large in comparison with that of
TcBnia solium, and measures over 2 mm. in breadth. It is square-shaped
and provided with four large sucking disks, but there are no hooklets. The
ripe segments are from 17 to 18 mm. in length and from 8 to 10 mm. in
breadth. The uterus consists of a median stem with from fifteen to thirty-
five lateral branches, which are given ofE more dichotomously than in Tcenia
solium. The ova are somewhat larger, and the shell is thicker, but the two
forms can scarcely be distinguished by their ova. The ripe segments are
passed as in Tcenia solium, and are ingested by cattle, in the flesh or organs
of which the eggs develop into the bladder worms or cysticerci.
Of other forms of tape-worm may be mentioned:
Dipylidium caninum (Taenia elliptica, Taenia cucumerina) . — A small
parasite very common in the dog and occasionally found in man; the larvaj
develop in the lice and fleas of the dog.
Hymenolepsis diminuta (Taenia flavo-punctata) . — This small cestode was
found in the intestine of a child in Boston, and has since been met with in
twelve cases (Eausom). It is common in rats. The larvae develop in Lepi-
doptera and in beetles.
Hymenolepsis nana (Taenia nana) occurs not infrequently in Italy.
It is not very uncommon in the United States (Stiles). The Davainea mada-
gascariensis (Tcenia madagascariensis) is a rare form.
Taenia confusa, a new species described by Ward.
Bothriocephalus latus. — A cestode worm found only in certain districts
bordering on the Baltic Sea, in parts of Switzerland, and in Japan. ISTicker-
son has shown that it is common among the Finns in the Northwestern States.
The parasite is large and long, measuring from 25 to 30 feet or more. Its
head is different from that of the taenia, as it possesses two lateral grooves
or pits and has no hooklets. The larvae develop in the peritonaeum and mus-
cles of the pike and other fish, and it has been shown experimentally that they
grow into the adult worm when eaten by man.
Symptoms. — These parasites are found at all ages. They are not uncom-
mon in children and are occasionally found in sucklings. W. T. Plant refers
to a number of cases in children under two years, and there is one in the liter-
ature in which it is stated that the tape-worm was found in an infant five
days old !
The parasites may cause no disturbance and are rarely dangerous. A
knowledge of the existence of the worm is generally a source of worry and
30 DISEASES DUE TO ANIMAL PARASITES.
anxiety; the patient may have considerable distress and complain of ab-
dominal pains, nausea, diarrhoea, and sometimes anemia. Occasionally the
appetite is ravenous. In women and in nervous patients the constitutional
disturbance may be considerable, and we not infrequently see great mental
depression and even hypochondria. Various nervous phenomena, such as
chorea, convulsions, or epilepsy, are believed to be caused by the parasites.
Such effects, however, are very rare. The Bothriocephalus may cause a
severe and even fatal form of anaemia, which has been described fully in
the monograph of Schaumann, of Helsingfors. It has been suggested that
the metabolic products of the worm may have in some cases a hsemolytic
action.
The diagnosis is never doubtful. The presence of the segments is dis-
tinctive. The ova, too, may be recognized in the stools. It makes but little
difference as to the form of tape-worm, but the ripe segments of Tcenia sagi-
nata are larger and broader, and show differences in the generative system as
already* mentioned.
The prophylaxis is most important. Careful attention should be given to
three points. First, all tape- worm segments should be burned; they should
never be thrown into the water-closet or outside ; secondly, careful inspection
of meat at the abattoirs; and thirdly, cooking the meat sufficiently to kill the
parasites.
In the case of the beef measles, the distribution of the parasites, as
given by Ostertag, shows that the muscles of the jaw are much more fre-
quently affected than other parts — 360 times, while other organs were infected
but 55 times. Sometimes there are instances of general infection. Stiles
states that no exact statistics have been published for this country. In Ber-
lin the proportion of cattle infected in 1892-'93 was about 1 to 672. Cold
storage kills the cysticercus usually within three weeks. The measles are
more readily overlooked in beef than in pork, as they do not present such an
opaque white color.
In the examination of hogs for cysticerci " particular stress should be
laid upon the tongue, the muscles of mastication, and the muscles of the
shoulder, neck, and diaphragm" (Stiles). They may be seen very easily
on the under surface of the tongue. American hogs are comparatively
free. In Prussia one hog is infected in about every 637. Specimens have
been found alive twenty-nine daj^s after slaughtering. In the examination
of 1,000 hogs in Montreal, Clement and I found 76 instances of cysticerci.
For full details with reference to the inspection of meat for animal parasites,
the practitioner is referred to the work of Dr. Stiles, in Bulletin No. 19,
United States Department of Agriculture, 1898.
Treatment. — For two days prior to the administration of the reme-
dies the patient should take a very light diet and have the bowels moved
occasionally by a saline cathartic. The practitioner has the choice of a large
number of drugs. As a rule, the male fern acts promptly and well. The
ethereal extract, in 2-drachm doses, may be given fasting, and followed in the
course of a couple of hours by a brisk purgative. This usually succeeds in
bringing away a large portion, but not always the entire worm.
A combination of the remedies is sometimes very effective. An infusion
is made of pomegranate root, half an ounce; pumpkin seeds, 1 ounce; pow-
DISEASES CAUSED BY CESTODES. 31
dered. ergot, a drachm ; and boiling water, 10 ounces. To an emulsion of the
male fern (a drachm of ethereal extract), made with acacia powder, 2 minims
of croton oil are added. The patient should have had a low diet the previous
day and have taken a dose of salts in the evening. The emulsion and infusion
are mixed and taken fasting at nine in the morning.
The pomegranate root is a very efficient remedy, and may be given as
an infusion of the bark, 3 ounces of which may be macerated in 10 ounces
of water and then reduced to one half by evaporation. The entire quan-
tity is then taken in divided doses. It occasionally produces colic, but is
a very effective remedy. The active principle of the root, pelletierine, is
now much employed. It is given in doses of 6 to 8 or even 10 grains, with
a little tannin (grs. v) in sweetened water, and is followed in an hour by a
purge.
Pumpkin seeds are sometimes very efficient. Three or 4 ounces should
be carefully bruised and then macerated for twelve or fourteen hours, and
the entire quantity taken and followed in an hour by a purge. Of other
remedies, koosso, turpentine in ounce doses in honey, and kamala may be
mentioned.
Unless the head is brought away, the parasite continues to grow, and
within a few months the segments again appear. Some instances are
extraordinarily obstinate. Doubtless almost everything depends upon the
exposure of the worm. The head and neck may be thoroughly protected
beneath the valvulse conniventes, in which case the remedies may not act.
Owing to its armature Tcenia solium is more difficult to expel. It is probable
that no degree of peristalsis could dislodge the head, and unless the worm is
killed it does not let go its extraordinarily firm hold on the mucous mem-
brane. If hot water be put in the commode the worm is less likely to con-
tract and be broken, a practice recommended by Celsus.
II. SOMATIC T-ffiNIASIS.
Whereas adult taenia may give rise to little or no disturbance, and rarely,
if ever, prove directly fatal, the affections caused by the larvae or immature
forms in the solid organs are serious and important. There are two chief
cestode larvas known to frequent man : (a) the Cysticercus cellulosce, the larva
of Tcenia solium, and (&) the Ecliinococcus, the larva of Tcenia echinococcus.
The Cysticercus tcenice saginatce has been found only two or three times
in man.
Cysticercus Cellulosae. — When man accidentally takes into his stomach
the ripe ova of Tania solium he is liable to become the intermediate host,
a part usually played for this tape-worm by the pig. This accident may
occur in an individual the subject of Tcenia solium, in which case the mature
proglottides either themselves wander into the stomach or, what is more likely,
are forced into the organ in attacks of prolonged vomiting. Of course the
accidental ingestion from the outside of a few ova is quite possible, and the
liability of infection should always be borne in mind in handling the seg-
ments of the worm.
The symptoms depend entirely upon the number of ova ingested and
S2 DISEASES DUE TO ANIMAL PARASITES.
the localities reached. In the hog the cysticerci produce very little dis-
turbance. The muscles, the connective tissue, and the brain may be swarm-
ing with the measles, as they are called, and yet the nutrition is maintained
and the animal does not appear to be seriously incommoded. In the in-
vasion period, if large numbers of the parasites are taken, there is, in all
probability, constitutional disturbance ; certainly this is seen in the calf, when
fed with the ripe segments of Tcenia saginata.
In man a few cysticerci lodged beneath the skin or in the muscles give
no trouble, and in time the larvae die and become calcified. They are occa-
sionally found in dissection subjects or in post mortems as ovoid white bodies
in the muscles or subcutaneous tissue. In America they are very rare. I
saw but one instance in my post-mortem experience. Depending on the num-
ber and the locality specially affected, the symptoms may be grouped into gen-
eral, cerebro-spinal, and ocular. In 155 cases compiled by Stiles, the para-
site in 117 was found in the brain, in 3.2 in the muscles, in 9 in the heart,
in 3 in the lungs, subcutaneously in 5, in the liver in 2.
1. General. — As a rule the invasion of the larvae in man, unless in very
large numbers, does not cause very definite symptoms. It occasionally hap-
pens, however, that a striking picture is produced. A patient was admitted
to my wards very stiff and helpless, so much so that he had to be assisted
upstairs and into bed. He complained of numbness and tingling in the
extremities and general weakness, so that at first he was thought to have a
peripheral neuritis. At the examination, however, a number of painful subcu-
taneous nodules were discovered, which proved on excision to be the cysticerci.
Altogether 75 could be felt subcutaneously, and from the soreness and stiff-
ness they probably existed in large numbers in the muscles. There were none
in his eyes, and he had no brain symptoms.
2. Cerebro-spinal. — Remarkable symptoms may result from the presence
of the cysticerci in the brain and cord. In the silent region they may be
abundant without producing any symptoms. I have in my possession the
brain of a pig containing scores of " measles," yet the animal in the few
moments in which I saw it just prior to death did not present any symptoms
to attract attention. In the ventricles of the brain the cysticerci may attain
a considerable size, owing to the fact that in regions in which they are unre-
strained in their growth, as in the peritonseum, the bladder-like body grows
freely. When in the fourth ventricle, remarkable irritative symptoms may be
produced. In 1884 I saw with Friedlander in Berlin a case from Riess's
wards in which during life there had been symptoms of diabetes and anom-
alous nervous symptoms. Post mortem, the cysticercus was found beneath
the valve of Vieussens, pressing upon the floor of the fourth ventricle.
3. Ocular. — Since von Graefe demonstrated the presence of the cysticer-
cus in the vitreous humor many cases have been placed on record, as it is a
condition easily recognized.
Except in the eye, the diagnosis can rarely be made; when the cysticerci
are subcutaneous, one may be excised. It is possible that when numerous
throughout the muscles they may be seen under the tongue, in which situa-
tion they may exist in the pig in numbers.
Echinococcus Disease. — The hydatid worms or echinococci are the larvae
of Tcenia echinococcus of the dog. This is a tiny cestode not more than 4
DISEASES CAUSED BY CESTODES. 33
or 5 mm. in length, consisting of only three or four segments^ of which
the terminal one alone is mature, and has a length of about 3 mm. and a
breadth of 0.6 mm. The head is small and provided with four sucking
disks and a rostellum with a double row of booklets. This is an exceedingly-
rare parasite in the dog. Cobbold states that he has never met with a natural
specimen in England. Leidy had not one in his large collection. I have not
met with an instance in America; Curtice, of Washington, found it once in
an American dog. The worms are so small that they may be readily over-
looked, since they form small white, thread-like bodies closely adherent among
the villi of the small intestines. The ripe segment contains about 5,000 eggs,
which attain their development in the solid organs of various animals, particu-
larly the hog and ox, more rarely the horse and the sheep. In some countries
man is a common intermediate host, owing to the accidental ingestion of
the ova.
Development. — The little six-hooked embryo, freed from the egg-shell by
digestion, burrows through the intestinal wall and reaches the peritoneal cav-
ity or the muscles ; it may enter the portal vessels and be carried to the liver.
It maj'' enter the systemic vessels, and, passing the pulmonary capillaries, as it
is protoplasmic and elastic, may reach the brain or other parts. Once having
reached its destination, it undergoes the following changes : The hooklets
disappear and the little embryo is gradually converted into a small cyst which
presents two distinct layers — an external, laminated, cuticular membrane or
capsule, and an internal, granular, parenchymatous layer, the endocyst. The
little cyst or vesicle contains a clear fluid. There is more or less reaction in
the neighboring tissues, and the cyst in time has a fibrous investment. When
this primary cyst or vesicle has attained a certain size, buds develop from
the parenchymatous layer, which are gradually converted into cysts, present-
ing a structure identical with that of the original cyst, namely, an elastic
chitinous membrane lined with a granular parenchymatous layer. These sec-
ondary or daughter cysts are at first connected with the lining membrane of
the primary cyst, but are soon set free. In this way the parent cyst as it
grows may contain a dozen or more daughter cysts. Inside these daughter
cysts a similar process may occur, and from buds in the walls granddaughter
cysts are developed. From the granular layer of the parent and daughter
cysts buds arise which develop into brood capsules. From the lining mem-
brane the little outgrowths arise and gradually develop into bodies known as
scolices, which represent in reality the head of the Tcenia echinococcus and
present four sucking disks and a circle of hooklets. Each scolex is capable
when transferred to the intestines of a dog of developing into an adult tape-
worm. The difference between the ovum of an ordinary tape-worm, such
as Tcenia solium^ and Tcenia echinococcus is in this way very striking. In
the former case the ovum develops into a single larva — Cysticercus cellulosce
— whereas the egg of Tcenia echinococcus develops into a cyst which is capa-
ble of multiplying enormously and from the lining membrane of which
millions of larval tape-worms develop. Ordinarily in man the development of
the echinococcus takes place as above mentioned and by an endogenous form
in which the secondary and tertiary cysts are contained within the primary;
but in animals the formation may be different, as the buds from the primary
cyst penetrate between the layers and develop externally, forming the exoge-
4
34 DISEASES DUE TO ANIMAL PARASITES.
nous variety. A third form is the multilocular echinococciis, in which form
the primary cj^st huds develop which are cut off completely and are sur-
rounded by thick capsules of a connective tissue, which join together and
ultimately form a hard mass represented hy strands of connective tissue
enclosing alveolar spaces about the size of peas or a little larger. In these
spaces are found the remnants of the eehinococcus cyst, occasionally the
scolices or booklets, but they are often sterile.
The fluid is limpid, non-albuminous; specific gravity 1.005 to 1.009, occa-
sionally higher. It ma}' contain sugar and succinic acid, and after repeated
tapping of the cyst, albumin. When not degenerated, the hydatid heads or
the characteristic booklets are found in the contents of the cyst.
Chaxgbs IX THE Cyst. — It is not known definitely how long the eehino-
coccus remains alive, probably many years, possibly as long as twent}' years.
The most common change is death and the gradual inspissation of the contents
and conversion of the cyst into a mass containing putty-like or granular mate-
rial which may be partially calcified. Eemnants of the chitinous cyst wall or
booklets may be found. These obsolete hydatid cysts are not infrequently
found in the liver. A more serious termination is rupture, which may take
place into a serous sac, or perforation may take place externally, when the
cysts are discharged, as into the bronchi or alimentary canal or urinary
passages. More unfavorable are the instances in which rupture occurs into
the bile-passages or into the inferior cava. Eecovery ma}' follow the rupture
and discharge of the hydatids externally. Sudden death has been known to
follow the rupture. A third and very serious mode of termination is suppura-
tion, which may occur spontaneously or follow rupture and is found most
frequently in the liver.
Geographical Distribution op the Echinococcus. — The disease pre-
vails most extensively in those countries in which man is brought into close
contact with the dog, particularly when, as in Australia, the dogs are used for
herding sheep, the animal in which the larval form of Tcenia eehinococcus is
most often found. In Iceland the cases are very numerous. In Europe the
disease is not uncommon. In Great Britain and in North America it is
rare, and a majority of the cases are in foreigners. Statistics of the preva-
lence of the disease in America have been published by Osier (1882), Som-
mer (1895-'96), and by Lyon (1902), who has collected 211 cases. Of these,
136 cases were in foreigners; in 92 the nationality was not stated; 10 were
negroes; 2 Canadians, and only 1 a native American. Fifty-six cases oc-
curred in Manitoba, in which province there is a large settlement of Icelanders,
who have brought the disease with them. Only one instance is known in a
Canadian-born ofl^spring of an Icelandic emigrant.
Distribution in the Body. — Of 1,634 cases comprised in the statistics
of -Davaine, Boeker, Finsen, and Neisser, the parasite existed in the liver in
820; in the lung or pleura in 137; in the abdominal organs, including the
kidneys, bladder, and genitalia, in 331 ; in the nervous system in 122 ; in the
circulatory system in 42; in other organs 179. Of the 241 eases in Lyon's
series in this country the liver was the seat in 177, and the omentum, peri-
toneal cavity, and mesentery in 26. In 11 cases cysts were passed per rectum,
in 7 cases cysts or booklets were expectorated, and in 2 cases passed per
urethram.
DISEASES CAUSED BY CESTODES. 35
Symptoms. — 1. Hydatids of the Liver. — Small cysts may cause no dis-
turbance; large and growing cysts produce signs of tumor of the liver with
great increase in the size of the organ. Naturally the physical signs depend
much upon the situation of the growth. Near the anterior surface in the
epigastric region the tumor may form a distinct prominence and have a tense,
firm feeling, sometimes with fluctuation. A not infrequent situation is to
the left of the suspensory ligament, the resulting tumor pushing up the heart
and causing an extensive area of dulness in the lower sternal and left hypo-
chondriac regions. In the right lobe, if the tumor is on the posterior sur-
face, the enlargement of the organ is chiefly upward into the pleura and the
vertical area of dulness in the posterior axillary line is increased. Super-
ficial cysts may give what is known as the hydatid fremitus. If the tumor
is palpated lightly with the fingers of the left hand and percussed at the same
time with those of the right, there is felt a vibration or trembling movement
which persists for a certain time. It is not always present, and it is doubtful
whether it is peculiar to the hydatid tumors or is due, as Briangon held, to the
collision of the daughter cysts. Very large cysts are accompanied by feelings
of pressure or dragging in the hepatic region, sometimes actual pain. The
general condition of the patient is at first good and the nutrition little, if at
all, interfered with. Unless some of the accidents already referred to occur,
the symptoms indeed may be trifling and due only to the pressure or weight of
the tumor.
Historically, one of the most interesting cases is that of the first Lord
Shaftesbury (Achitopel), who had a tumor below the costal border for many
years. It suppurated and was opened by the philosopher John Locke, his
physician, who describes with great detail the escape of the bladder-like bodies.
Among the Shaftesbury papers in the Eecord Office are several other cases col-
lected by Locke ; the disease may have been more common in England at that
period.
Suppuration of the cyst changes the clinical picture into one of pyaemia.
There are rigors, sweats, more or less jaundice, and rapid loss of weight.
Perforation may occur into the stomach, colon, pleura, bronchi, or exter-
nally, and in some instances recovery has taken place. Perforation has occurred
into the pericardium and inferior vena cava; in the latter case the daughter
cysts have been found in the heart, plugging the tricuspid orifice and the
pulmonary artery. Perforation of the bile-passages causes intense jaundice,
and may lead to suppurative cholangitis.
An interesting symptom connected with the rupture of hydatid cysts is the
occurrence of urticaria, which may also follow aspiration of the cysts.
Brieger has separated a highly toxic material from the fluid, and to it the
symptoms of poisoning may be due.
Diagnosis. — Cysts of moderate size may exist without producing symp-
toms. Large multiple echinococci may cause great enlargement with irregu-
larity of the outline, and such a condition persisting for any time with reten-
tion of the health and strength suggests hydatid disease. An irregular, pain-
less enlargement, particularly in the left lobe, or the presence of a large,
smooth, fluctuating tumor of the epigastric region is also very suggestive,
and in this situation, when accessible to palpation, it gives a sensation of a
smooth elastic growth and possibly also the hydatid tremor. When suppu-
36 DISEASES DUE TO ANIMAL PARASITES.
ration occurs the clinical picture is really that of abscess, and only the exist-
ence of previous enlargement of the liver with good health would point to the
fact that the suppuration was associated with hydatids. Syphilis may pro-
duce irregular enlargement without much disturbance in the health, some-
times also a very definite tumor in the epigastric region, but this is usually
firm and not fluctuating. The clinical features may simulate cancer very
closely. In a case which I reported the liver was greatly enlarged and there
were many nodular tumors in the abdomen. The post mortem showed enor-
mous suppurating hydatid cysts in the left lobe of the liver which had
perforated the stomach in two places and also the duodenum. The omen-
tum, mesentery, and pelvis also contained numerous cysts. As a rule, the
clinical course of the disease would suffice to separate it clearly from cancer.
Dilatation of the gall-bladder and hydronephrosis have both been mistaken
for hydatid disease. In the former the mobility of the tumor, its shape, and
the mucoid character of the contents suffice for the diagnosis. In some in-
stances of hydronephrosis only the exploratory puncture could distinguish
between the conditions. More frequent is the mistake of confounding a
hydatid cyst of the right lobe pushing up the pleura with pleural effusion of
the right side. The heart may be dislocated, the liver depressed, and dulness,
feeble breathing, and diminished fremitus are present in both conditions.
Frerichs lays stress upon the different character of the line of dulness ; in the
echinococcus cyst the upper limit presents a curved line, the maximum of
which is usually in the scapular region. Suppurative pleurisy may be caused
by the perforation of the cyst. If adhesions result, the perforation takes
place into the lung, and fragments of the cysts or small daughter ejsts may
be coughed up. For diagnostic purposes the exploratory puncture should
be used. As stated, the fluid is usually perfectly clear or slightly opalescent,
the reaction is neutral, and the specific gravity varies from 1.005 to 1.009.
It is non-albuminous, but contains chlorides and sometimes traces of sugar.
Hooklets may be found either in the clear fluid or in the suppurating cysts.
They are sometimes absent, however, as the cyst may be sterile.
2. EcHixococcus OF THE Eespikatory System. — Of 809 cases of single
hydatid cyst collected by Thomas in Australia, the lung was affected in 134
cases. Of 241 American cases, in 16 the pleura or lung was affected. The
larvas may develop primarily in the pleura and attain a large size. The
s}Tnptoms are at first those of compression of the lung and dislocation of the
heart. The physical signs are those of fluid in the pleura. The line of dul-
ness may be quite irregular. As in the echinococcus of the liver, the general
condition of the patient may be excellent in spite of the existence of extensive
disease. Pleurisy is rarely excited. The cysts may become inflamed and
perforate the chest wall. Cary and Lyon have analyzed 40 cases of primary
echinococcus cjst of the pleura; death results in a majority of the cases from
the toxgemia following the rupture and the absorption of the fluid or from
the sepsis following suppuration.
Echinococci occur more frequentty in the lung than in the pleura. If
small, they may exist for some time without causing serious s}TiLptoms. In
their growth they compress the lung and sooner or later lead to inflamma-
tory processes, often to gangrene, and the formation of cavities which connect
with the bronchi. Fragments of membrane or small cysts may be expectorated.
DISEASES CAUSED BY CESTODES. 37
HEemorrhage is not infrequent. Perforation into the pleura with empyema
is common. A majority of tlie cases are regarded during life as either phthi-
sis or gangrene, and it is only the detection of the characteristic membranes
or the booklets which leads to the diagnosis. Of a series of 21 cases, 17 recov-
ered; 5 of the cases suppurated (C. H. Fleming, Victoria, personal communi-
cation) .
3. EcHiNOCOccus OF THE KiDNEYS. — In the collected statistics referred
to above, the genito-urinary system comes second as the seat of hydatid disease,
though here the affection is rare in comparison with that of the liver. ' Of
the 341 American cases, there were 17 in which the kidneys or bladder were
involved. The kidney may be converted into an enormous cyst resembling a
hydronephrosis.
The diagnosis is only possible by puncture and examination of the fluid.
The cyst may perforate into the pelvis of the kidney, and portions of the
membrane or cj'^sts may be discharged with the urine, sometimes producing
renal colic. I have reported a case in which for many months the patient
passed at intervals numbers of small cysts with the urine. The general health
was little if at all disturbed, except by the attacks of colic during the passage
of the parasites.
4. EcHiNOCOCCUS OF THE Kervous System. — The common cystic disease
of the choroidal plexuses has been mistaken for hydatids. Davies Thomas, of
Australia, has tabulated 97 cases, including some of the Cysticercus cellu-
loses. According to his statistics, the cyst is more common on the right than
on the left side, and is most frequent in the cerebrum.
The symptoms, very indefinite, as a rule, are those of tumor. Persistent
headache, convulsions, either limited or general, and gradually developing
blindness have been prominent features in many cases.
Multilocular Echinococcus. — This form merits a brief separate descrip-
tion, as it differs so remarkably from the usual type. It has been met
with only in Bavaria, Wlirtemberg, the adjacent districts of Switzerland, and
in the Tyrol. Possett has reported 13 cases from von Eokitansky's clinic at
Innsbruck. In the United States six cases have been described, chiefly in Ger-
mans. Delafield and Prudden's patient had lived there five years, and for a
year before his death had been jaundiced. A fluctuating tumor was found
in the right flank, apparently connected with the liver. This was opened, and
death followed from haemorrhage. In Oertel's case the patient had lived there
ten years. He was deeply jaundiced, and had a tumor mass at the right bor-
der of the liver, which was enlarged. Bacon resected a cyst from the left lobe
of the liver. The primary tumor presents irregularly formed cavities sepa-
rated from each other by strands of connective tissue, and lined with the
echinococcus membrane. The cavities are filled with a gelatinous material, so
that the tumor has very much the appearance of an alveolar colloid cancer.
It is quite possible that a special form of taenia echinococcus represents the
adult type of this peculiar parasite. This form is almost exclusively confined
to the liver, and the symptoms resemble more those of tumor or cirrhosis.
The liver is, as a rule, enlarged and smooth, not irregular as in presence of
the ordinary echinococcus. Jaundice is a common symptom. The spleen is
usually enlarged, there is progressive emaciation, and toward the close hsem-
orrhages are common.
38 DISEASES DUE TO ANIMAL PARASITES.
Treatment of Echinococcus Disease. — Medicines are of no avail. Post-
mortem reports show that in a considerable number of cases the parasite
dies and the cyst becomes harmless. Operative measures should be resorted
to when the cyst is large or troublesome. The simple aspiration of the con-
tents has been successful in a large number of cases, and as it is not in any
way dangerous, it may be tried before the more radical procedure of incision
and evacuation of the cysts. Suppuration has occasionally followed the punc-
ture. Injections into the sac should not be practised. With modern methods
surgeons now open and evacuate the echinococcus cysts with great boldness,
and the Australian records, which are the most numerous and important on
this subject, show that recovery is the rule in a large proportion of the cases.
Suppurative cysts in the liver should be treated as abscess. ISTaturally the
outlook is less favorable. The practical treatment of h3'datid disease has been
greatly advanced by Australian surgeons. The works of the Australian
physicians James Graham and Thomas may be consulted for interesting
details in diagnosis and treatment.
E. DISEASES CAUSED BY NEMATODES.
I. ASCARIASIS.
Ascaris Lumbricoides, the most common human parasite, is found chiefly
in children. The female is from 7 to 12 inches in length, the male from
4 to 8 inches. In form it is cylindrical, pointed at both ends, with a yel-
lowish-brown, sometimes a slightly reddish color. Four longitudinal bands
can be seen, and it is striated transverseh''. The ova, which are sometimes
found in large numbers in the faeces, are small, brownish-red in color, elliptical,
and have a very thick covering. They measure 0.075 mm. in length and 0.058
mm. in width. The life history has been demonstrated to be " direct " — i. e.,
without intermediate host. The parasite occupies the upper portion of the
small intestine. Usually not more than one or two are present, but occasion-
ally they occur in enormous numbers. The migrations are peculiar. They
may pass into the stomach, whence thej^ may be ejected by vomiting, or they
may crawl up the oesophagus and enter the phar^mx, from which they may be
withdrawn. A child under my care in the small-pox department of the
Montreal General Hospital, during convalescence, withdrew in this way more
than thirty round worms within a few weeks. In other instances the worm
reaches the larynx, and has been known to produce fatal asphyxia, or, passing
into the trachea, to cause gangrene of the lung. They may go through the
Eustachian tube and appear at the external meatus. The worms have been
found in extraordinary numbers in the bile-ducts. Eemarkable specimens
exist in the Dupuytren, the Wistar-Horner (Philadelphia), and the N'etley
Museums. Chalmers (Ceylon) and Leys (U. S. jST.) have called attention to
their importance in causing abscess of the liver. Ebstein reports certain
markings, strangulations, on the round worm, as if they had been nipped in
the bile-ducts ! The bowel may be blocked, or in rare instances an ulcer may be
perforated. Even the healthy bowel wall may be penetrated (Apostolides).
A peculiarly irritating substance, often evident to the sense of smell in
DISEASES CAUSED BY NEMATODES. 39
handling specimens, is formed by the round worms. Peiper and others sug-
gest that the nervous symptoms, sometimes resembling those of meningitis,
are due to this poison. Chauffard, Marie, and Tauchon have gone still fur-
ther, and report a remarkable condition of fever, intestinal symptoms, foul
breath, and intermittent diarrhoea in connection with the presence of lum-
bricoides. They call it typho-lumbricosis. The febrile condition may con-
tinue for a month or more. There may be eosinophilia to 25 per cent to 30
per cent, and in some cases a marked anaemia. The question of the toxins
produced by intestinal parasites is still an open one.
A few parasites may cause no disturbance. In children there are irrita-
tive symptoms usually attributed to worms, such as restlessness, irritability,
picking at the nose, grinding of the teeth, twitchings, or convulsions.
Treatment. — Santonin can be given, mixed with sugar, in doses of from
one half to one grain for a child and two to three grains for an adult, fol-
lowed by a calomel or a saline purge. The dose may be given for three or
four days. An unpleasant consequence which sometimes follows the admin-
istration of this drug is xanthopsia or yellow vision.
Oxyuris Vermicularis (Thread-worm; Pin-worm). — This common para-
site occupies the rectum and colon. The male measures about 4 mm. in
length, the female about 10 mm. They produce great irritation and itching,
particularly at night, symptoms which become intensely aggravated by the
nocturnal migration of the parasites. The oxyuris may traverse the intes-
tinal wall, and has been found in the peritoneal cavity, where they may form
verminous tubercles in Douglas's fossa or peri-rectal abscesses.
The patients become extremely restless and irritable, the sleep is often
disturbed, and there may be loss of appetite and ansemia. Though most
common in children, the parasite occurs at all ages.
The worm is readily detected in the faeces. Infection probably takes place
through the water, or possibly through salads, such as lettuce and cresses. A
person the subject of the worms passes ova in large numbers in the faeces, and
the possibility of reinfection must be scrupulously guarded against.
The treatment is simple, though occasionally there are instances in which
all forms of medication are resisted. A case is mentioned of a gentleman,
aged forty, who had suffered from childhood and had failed to obtain any
benefit from prolonged treatment by many helminthologists. Santonin may
be used in small doses, and mild purgatives, particularly rhubarb. Large
injections containing carbolic acid, vinegar, quassia, aloes, or turpentine may
be employed. In children the use of cold injections of strong salt and water
is usually efficacious. They should be repeated for at least ten days. In
giving the injection care should be taken to have the hips well elevated, so
that the fluid can be retained as long as possible. For the intense itching
and irritation at night, vaseline may be freely used, or belladonna ointment.
The " cat " ascaris and the " dog " ascaris are occasional parasites in man.
II. TRICHINIASIS.
The Trichina spiralis in its adult condition lives in the small intestine.
The disease is produced by the embryos, which pass from the intestines and
reach the voluntary muscles, where they finally become encapsulated larvae — ■
40 DISEASES DUE TO ANIMAL PARASITES.
muscle trichina. It is in the migration of the embryos (possibly from poisons
produced by them) that the group of symptoms known as trichiniasis is
produced.
The ovoid cysts were described in human muscle by Tiedemann in 1833,
and by Hilton in 1833; the parasite was figured and named by Kichard Owen.
Leidy in 1845 described it in the pig. For a long time the trichina was looked
upon as a pathological curiosity; but in 1860 Zenker discovered in a girl in
the Dresden Hospital, who had sjonptoms of typhoid fever, both the intestinal
and muscle forms, and established their connection with a serious and often
fatal disease.
Description of the Parasites. — (a) Adult or intestinal form. The female
measures from 3 to 4 mm.; the male, 1.5 mm., and has two little projections
from the hinder end.
(b) The larva or muscle trichina is from 0.6 to 1 mm. in length and lies
coiled in an ovoid capsule, which is at first translucent, but subsequently
opaque and infiltrated with lime salts. The worm presents a pointed head
and a somewhat rounded tail.
When flesh containing the trichinse is eaten by man or by any animal in
which the development can take place, the capsules are digested and the
trichinas set free. They pass into the small intestine, and about the third
day attain their full growth and become sexually mature. Virchow's experi-
ments have shown that on the sixth or seventh day the embryos are fully
developed. The young produced by each female trichina have been estimated
at several hundred. Leuckart thinks that various broods are developed in
succession, and that as many as a thousand embryos may be produced by a
single worm. The time from the ingestion of the flesh containing the muscle
trichina to the development of the brood of embryos in the intestines is from
seven to nine days. The female worm penetrates the intestinal wall and the
embryos are probably discharged directly into the IjTnph spaces (Askanazy),
thence into the venous system, and by the blood stream to the muscles, which
constitute their seat of election. J. Y. Graham reviewed the question of the
mode of transmission in an exhaustive monograph, and he gives strong argu-
ments in favor of the transmission through the blood stream. After a pre-
liminary migration in the intermuscular connective tissue they penetrate the
primitive muscle-fibres, and in about two weeks develop into the full-grown
muscle form. In this process an interstitial myositis is excited and gradually
an ovoid capsule develops about the parasite. Two, occasionally three or four,
worms may be seen within a single capsule. This process of encapsulation
has been estimated to take about six weeks. Within the muscles the parasites
do not undergo further change. Gradually the capsule becomes thicker, and
ultimately lime salts are deposited within it. This change may take place in
man within four or five months. In the hog it may be deferred for many
years. The calcification renders the cyst visible, and since first seen by Tiede-
mann and Hilton, these small, opaque, oat-shaped bodies have been familiar
objects to demonstrators of normal and morbid anatomy. The trichina may
live within the muscles for an indefinite period. They have been found alive
and capable of developing as late as twenty or even twenty-five years after
their entrance into the system. In many instances, however, the worms are
completely calcified. The trichina has been found or " raised " in twenty-six
DISEASES CAUSED BY NEMATODES. 41
different species of animals (Stiles). Medical literature abounds in refer-
ences to its presence in fish, earthworms, etc., but these parasites belong to
other genera. In fsecal examinations for the parasite it is well to remember
that the " cell body " of the anterior portion of the intestine is a diagnostic
criterion of the T. spiralis. Experimentally, guinea-pigs and rabbits are read-
ily infected by feeding them with muscle containing the larval form. Dogs
are infected with difficulty ; cats more readily. Experimentally, animals some-
times die of the disease if large numbers of the parasites have been eaten. In
the hog the trichinae, like the cysticerci, cause few if any symptoms. An animal
the muscles of which are swarming with living trichinge may be well nourished
and healthy-looking. An important point also is the fact that in the hog the
capsule does not readily become calcified, so that the parasites are not visible
as in the human muscles.
Incidence. — Man is infected by eating the flesh of trichinous hogs. In
Germany, where a thorough and systematic microscopic examination of all
swine flesh is made, the proportion of trichinous hogs is about 1 in 1,852. At
the Berlin abattoir, where the microscopic examination is conducted by a
staff of over eighty men and women, two portions are taken from the abdom-
inal muscles, from the diaphragm, and from the intercostal muscles, and one
piece from the muscles of the larynx and tongue. A special compressor is
used to flatten the fragments of the muscle, and the examination is made
with a magnifying power of from 70 to 100 diameters. Statistics are not
available in England. In America inspections have been made since 1893.
The percentage of animals found infected has ranged from 1.04 to 1.95.
In- 1883, in conjunction with A. W. Clement, I examined 1,000 hogs at
the Montreal abattoir, and found only 4 infected.
Modes of Infection. — The danger of infection depends entirely upon
the mode of preparation of the flesh. Thorough cooking, so that all parts
of the meat reach the boiling point, destroys the parasites ; but in large joints
the central portions are often not raised to this temperature. The frequency
of the disease in different countries depends largely upon the habits of the
people in the preparation of pork. In North Germany, where raw ham and
Wurst are freely eaten, the greatest number of instances have occurred. In
South Germany, France, and England cases are rare. In the United States
the greatest number of persons attacked have been Germans. Salting and
smoking the flesh are not always sufficient, and the Havre experiments showed
that animals are readily infected when fed with portions of the pickled or
the smoked meat as prepared in America. Carl Fraenkel, however, states
that the experiments on this point have been negative, and that it is very
doubtful if any cases of trichiniasis in Germany have been caused by Amer-
ican pork. Germany has yet to show a single case of trichiniasis due to pork
of unquestioned American origin.
Frequency of Infection. — H. U. Williams, of Buffalo, made a thorough
study of the muscle from 505 unselected autopsies, and found 27 cases of
trichiniasis, 5.3 per cent. The subjects had all died of causes other than
trichiniasis. This important study shows how wide-spread is the disease,
and that in reality we frequently overlook the sporadic form, a mistake which
is now less often made, owing to T. E. Brown's discovery of the associated
eosinophilia.
42 DISEASES DUE TO AXIMAL PARASITES.
The disease often occurs in epidemics, a large number of persons being
infected from a single source. Among the best known of these, one occurred
at Hedersleben, in which there were 337 persons affected, and another at
Emersleben, in which there were 250 persons attacked. The extensive out-
breaks of this sort have been, with few exceptions, in jSTorth Germany, and
they are a comment on the inefficiency of the inspection. The statistics on
the subject in the United States by Alfred Mann, by the late F. A. Packard,
of Philadelphia, and more exhaustively by C. W. Stiles, who states that up
to 1893 there was a total of 709 cases; since then he says, in a letter, 1898,
there have been 40 or 50 cases reported. He thinks that 900 would cover
the total number reported to that date. According to States, New York
heads the list with 129 cases; Illinois shows 119; Massachusetts, 115; Iowa,
108, Xo doubt many cases escape detection, and the disease is not very un-
common. The sporadic cases are often overlooked. Seven cases occurred in
my wards within a few years.
Symptoms. — The ingestion of trichinous flesh is not necessarily followed
by the disease. When a limited number are eaten only a few embryos pass to
the muscles and may cause no symptoms. Well-characterized cases present
a gastro-intestinal period and a period of general infection.
In the course of a few days after eating the infected meat there are signs
of gastro-intestinal disturbance — pain in the abdomen, loss of appetite, vomit-
ing, and sometimes diarrhoea. The preliminary symptoms, however, are by
no means constant, and in some of the large epidemics cases have been ob-
served in which they have been absent. In other instances the gastro-intestinal
features have been marked from the outset, and the attack has resembled
cholera nostras. Pain in different parts of the body, general debility, and
weakness have been noted in some of the epidemics.
The invasion s^Tuptoms occur betAveen the seventh and the tenth day,
sometimes not until the end of the second week. There is fever, except in
very mild cases. Chills are not common. The thermometer may register
102° or 104°, and the fever is usually remittent or intermittent. The migra-
tion of the parasites into the muscles excites a more or less intense myositis,
which is characterized by pain on pressure and movement, and by swelling and
tension of the muscles, over which the skin may be oedematous. The limbs
are placed in the positions in which the muscles are in least tension. The
involvement of the muscles of mastication and of the larynx may cause diffi-
cult)' in chewing and swallowing. In severe cases the involvement of the dia-
phragm and intercostal muscles may lead to intense dyspnoea, which sometimes
proves fatal. CEdema, a feature of great importance, may be early in the face,
particularly about the eyes. Later it occurs in the extremities when the swell-
ing and stiffness of the muscles are at their height. Profuse sweats, tingling
and itching of the skin, and in some instances urticaria, have been described.
Blood. — A marked leucoc}i:osis, which may reach above 30.000, is present.
A special feature is the extraordinary increase in the number of eosinophilic
cells, which may comprise more than 50 per cent of all the leucocytes. There
were in four years, in the Jolins Hopkins Hospital, 7 cases in which this eosin-
ophilia was most pronounced. In 4 of them the diagnosis was actually sug-
gested by the great increase in the eosinophiles ; in 1 case they reached 68
per cent of the total number of leucocytes.
DISEASES CAUSED BY NEMATODES. 43
The general nutrition is much disturbed and the patient becomes emaci-
ated and often anaemic, particularly in the protracted cases. The patellar
tendon reflex may be absent. The patients are usually conscious, except in
cases of very intense infection, in which the delirium, dry tongue, and tremor
give a picture suggesting typhoid fever. In addition to the dyspnoea present
in the severer infections, there may be bronchitis, and in the fatal cases pneu-
monia or pleurisy. In some epidemics polyuria has been a common symptom.
Albuminuria is frequent.
The intensity and duration of the symptoms depend entirely upon the
grade of infection. In the mild cases recovery is complete in from ten to
fourteen days. In the severe forms convalescence is not established for six
or eight weeks, and it may be months before the patient recovers the muscular
strength. One case in the Hedersleben epidemic was weak eight years after
the attack.
Of 73 fatal cases in the Hedersleben epidemic, the greatest mortality oc-
curred in the fourth and fifth and sixth weeks ; namely, 53 cases. Two died
in the second week with severe choleraic symptoms.
The mortality has ranged in difl:erent outbreaks from 1 or 3 per cent to
30 per cent. In the Hedersleben epidemic 101 persons died. Among 456
cases reported in the United States there were 133 deaths.
The anatomical changes are chiefly in the voluntary muscles. The tri-
chinae enter the primitive muscle bundles, which undergo granular degenera-
tion with marked nuclear proliferation. There is a local myositis, and
gradually about the parasite a cyst wall is formed. These changes, as well
as the remarkable alterations in the blood, have been described in full by
Thomas R. Brown. Cohnheim has described a fatty degeneration of the
liver and enlargement of the mesenteric glands. At the time of death in
the fourth or fifth week or later, the adult trichinae are still found in the
intestines.
The prognosis depends much upon the quantity of infected meat which has
been eaten and the number of trichinae which mature in the intestines. In
children the outlook is more favorable. Early diarrhoea and moderately
intense gastro-intestinal symptoms are, as a rule, more favorable than con-
stipation.
Diagnosis. — The disease should always be suspected when a large birth-
day party or Fest among Germans is followed by cases of apparent typhoid
fever. The parasites may be found in the remnants of the ham or sausages
used on the occasion. The worms may be discovered in the stools. The stools
should be spread on a glass plate or black background and examined with a
low-power lens, when the trichinas are seen as small, glistening, silvery threads.
In doubtful cases the diagnosis may be made by the removal of a small frag-
ment of muscle. A special harpoon has been devised for this purpose, by
means of which a small portion of the biceps or of the pectoral muscle may
be readily removed. Under cocaine anaesthesia an incision may be made and
a small fragment removed. The disease may be mistaken for acute rheuma-
tism, particularly as the pains are so severe on movement, but there is no
special swelling of the joints. The great increase in the eosinophiles in the
blood is, as mentioned above, a most suggestive point in diagnosis. The
tenderness is in the muscles both on pressure and on movement. The intensity
44 DISEASES DUE TO ANIMAL PARASITES.
of the gastro-intestinal symptoms in some cases has led to the diagnosis of
cholera. Many of the former epidemics were doubtless described as typhoid
fever, which the severer cases, owing to the prolonged fever, the sweats, the
delirium, dry tongue, and gastro-intestinal symptoms, somewhat resemble.
The pains in the muscles, with tension and swelling, oedema, particularly
about the eyes, and shortness of breath, are the most important diagnostic
points.
Prophylaxis. — It is not definitely known how swine become diseased.
It has been thought that they are infected from rats about slaughter-houses,
but it is just as reasonable to believe that the rats are infected by eating
portions of the trichinous flesh of swine. The swine should, as far as possible,
be grain-fed, and not, as is so common, allowed to eat offal. The most satis-
factory prophylaxis is the complete cooking of pork and sausages, and to this
custom in England, France, South Germany, and the United States, immu-
nity is largely due.
Treatment. — If it has been discovered within twenty-four or thirty-six
hours that a large number of persons have eaten infected meat, the indications
are to thoroughly evacuate the gastro-intestinal canal. Purgatives of rhubarb
and senna may be given, or an occasional dose of calomel. Glycerin has been
recommended in large doses, in order that by pa^ssing into the intestines it may
by its hygroscopic properties destroy the worm. Male-fern, kamala, santonin,
and thymol have all been recommended in this stage. Turpentine may be
tried in full doses. There is no doubt that diarrhoea in the first week or ten
days of the infection is distinctly favorable. The indications in the stage
of invasion are to relieve the pains, to secure sleep, and to support the pa-
tient's strength. There are no medicines which have any influence upon the
embryos in their migration through the muscles.
III. ANKYLOSTOMIASIS.
(Uncinariasis ; Hook- Worm Disease ; Miner's Ansemia ; Egyptian Chlorosis, etc.)
History. — In 1843 Dubini first described the hook-worm in man. Grie-
singer demonstrated its connection with the Egyptian chlorosis, a disease
which Sandwith states is mentioned by the old Egyptian writers of between
three and four thousand years ago. Subsequently the disease was described
in the tunnel-workers at St. Gothard, and from this time on has been recog-
nized as an important cause of tropical anaemia and the anaemia of miners,
brick-workers, and tunnel-workers.
Incidence. — The parasite is widely spread in tropical and subtropical
countries, and is one of the most fatal of all parasitic diseases. In Porto
Eico, in 1906-7 more than 89,000 cases were treated by the permanent com-
mission. An attempt is being made to stamp out the disease, which causes
thousands of deaths, usually by a progressive anaemia with anasarca. While it
was known that a few cases occurred in the United States, it was not until the
interest aroused in tropical diseases by the Spanish-American War and the
work of Ashf ord in Porto Eico that the attention of American physicians was
called to the disease. Eeports of cases were published in 1901 and 1902, and
in the latter year Stiles took up the study of the problem and dem^onstrated to
DISEASES CAUSED BY NEMATODES. 45
the astonishment of the profession that the disease was endemic in many
places, and was tlie cause of the common anasmia of the Southern States.
It has been found among the miners in Pennsylvania, but fortunately not
to any great extent. In the Philippines it is not uncommon. Among the
miners of Germany and Austro-Hungary the disease has increased very much
of late years. The disease is very prevalent in Westphalia. During the year
1903, 3,000 patients were treated for ankylostomiasis in the Bochum Hospital.
In England much interest was aroused in the discovery by Haldane that the
ansemia of the Cornish miners was due to the ankylostoma. In Egypt the dis-
ease is very prevalent, not . only among the natives, but among the Indian
coolies. The superb monograph of Loos of the Government school, Cairo,
may be referred to for details of the biology of the parasite. It prevails
extensively in Queensland.
Parasite. — The worm is a strongyle, occurring in two forms, the Old-
World Ankylostoma duodenale and the New- World Uncinaria americana, de-
scribed by Stiles. Loos and Stiles now believe that the American species
should not be classed with Uncinaria, and the new name of Necator ameri-
canus is suggested. The parasites have the same general characters ; the males
are 7 to 11 mm. in length, the females 10 to 18 mm. The American worm is
the longer, and has well-marked specific peculiarities. The mouth is provided
with a heavy armature of sharp teeth, with which they pierce the mucosa
of the bowel, and by means of a strong muscular oesophagus suck the blood.
The male has a prominent caudal expansion or bursa. The eggs are 64 to
76 ^ by 36 to 40 /a in the American form, and 52 to 60 /* by 32 ju, in the Euro-
pean form; they are laid in segmentation, forming very characteristic bodies
in the faeces of infected persons.
The development is direct without an intermediate host. The embryo
lives in the water or moist ground and passes through the rhabditiform stage.
The mode of entrance into the body has been much discussed. The larvae may
live for months in the mud and water of the mines. It may be taken into the
body with the drinking-water or with the dirt from the hands of the miners
and tunnel-workers, or in the soil deliberately eaten in some instances by
the earth feeders — the geophagi — in the Southern States. Loos showed that
the embryo worms readily enter the skin and are carried by the veins to the
right side of the heart and to the lungs. Escaping from the pulmonary ves-
sels into the air spaces, they pass up the bronchi and trachea to the pharynx
and so down the gullet to the stomach and intestines. These remarkable obser-
vations of Loos have been confirmed by Schaudinn. Bentley, Allen J. Smith,
and others have suggested that the " ground-itch " of the tropics, a peculiar
form of dermatitis, may be due to the penetration of the skin by the anky-
lostoma embryos, and Boycott and Haldane think that the skin eruption
known as the " bunches " in the Cornish miners may be associated with the
entrance of the worms.
The adult worm lives in the small intestine, chiefly in the jejunum, but
it may be found in the duodenum or in the colon, rarely in the stomach. The
duration of life in the bowel has not been determined. It is probably a
matter of years. The liability to reinfection is of course very great.
Symptoms. — The following factors, referred to by Stiles in his monograph
(Hygienic Laboratory Bulletin, No. 10, Washington, 1903), have to be con-
46 DISEASES DUE TO ANIMAL PARASITES.
sidered: The constant drain on the system by the sucking of blood can no
longer as formerly be regarded as the chief cause of the anaemia. Through the
wounds bacterial infection may take place; the wall of the bowel may be
much thickened and degenerated, so that its functions are interfered with;
and, lastly, it is quite possible that toxic substances are produced by the para-
sites which act injuriously upon the patient. Blood is rarely found in the
stools.
A considerable number of parasites must be present to cause any symp-
toms. The investigations of many physicians in the Southern States have
shown that in some districts a very considerable percentage of even compara-
tively healthy children have the ova in the stools. Among miners the anaemia
may be absent, as sho-woi by the studies of Haldane and. Boycott in Cornwall.
Stiles groups the cases into the three divisions of light, medium, and severe.
At the onset in the stage of incubation there may be gastro-intestinal irrita-
tion, and, according to Sandwith, fever. In the advanced condition anaemia
is the most characteristic feature. The skin is of a dirty, muddy hue, some-
times of a waxy white color. In the Southern States it is known as the
Florida complexion. There is a lack of lustre in the eyes and a dull, heavy
expression, and Stiles tliinks there is something very characteristic about the
blank, lack-lustre stare in this disease. In children there is much interfer-
ence in the growth, so that they are stunted and ill-developed. As the dis-
ease advances and the anemia becomes more pronounced, the liver and the
spleen become somewhat enlarged, and there is an effusion into the abdomen,
so that there is a pot-bellied condition, due partly to the causes just men-
tioned and partly to the flatulent distention. OEdema of the feet is not
uncommon. The cardio-vascular features are those of severe anaemia — palpi-
tation, shortness of breath, cardiac bruits. In a very characteristic case in
my wards from Xorth Carolina, in which the blood was carefully studied
by Boggs, the red blood-corpuscles were 2,742,000, hasmoglobin 37 per cent,
leucocytes 55,000. The differential count gave pol}Tiuclear neutrophiles 51.8;
small mononuclears 26.4; large mononuclears 15.4; eosinophiles 4.6; mast-
cells 1.8. The eosinophilia is a most important feature of the disease, being
present in 94 per cent of the cases (Boycott and Haldane).
Diagnosis. — The diagnosis is very simple. The eggs are characteristic.
It is well to examine the stools after the use of the thjTnol. Stiles states
that the blotting-paper test is useful when a microscopical examination
can not be made. A portion of the faeces is placed upon white blotting-
paper, and if allowed to stand for about an hour there is a reddish-
bro-^Ti staiu suggestive of blood. Eosinophilia is a most valuable diag-
nostic sign.
Some idea of the intensity of the infection may be gained by the number
of ova in the cubic centimetre of faeces. Grasse, quoted by Manson, states that
from 150 to 180 eggs per cubic centimetre indicates an infection of about
1,000 worms.
Prophylaxis. — In the rural districts of the Southern States the disease
is associated with the absence of proper sanitary conditions, particularly
latrines, etc. The infection is more common in the summer than in the win-
ter, and whites appear to be relatively more frequently attacked than the
blacks. In infected regions the wearing of shoes should be made compulsory.
DISEASES CAUSED BY NEMATODES. 47
The prophylaxis in miners is an important national problem. New miners
should j)ass a careful medical examination. Infected miners before resuming
work should present a certificate of freedom from the disease. Each working
colliery should provide suitable closet accommodation, in infected mines, 1 to
every 20 men of the total staff. They are to be emptied and disinfected daily.
These regulations, adopted in Hungary, as given by Oliver, will do much to
limit the spread of the disease.
Prognosis. — The prognosis is good, except in the advanced cases of anae-
mia. The figures already stated from Porto Rico indicate its fatality under
suitable conditions. Ashford and King estimate that at least 30 per cent
of the deaths are due to it.
Treatment. — After a few days' preliminary dieting the patient is given
half a drachm of thymol, repeated in two hours, and then two hours later a
dose of castor oil. Sandwith states that about a drachm of thymol in the
twenty-four hours is perfectly efficacious. He recommends giving the thymol
in brandy or whisky. In very debilitated patients it should be given in smaller
doses and over a longer period. The stools should be carefully examined
at intervals of a few days, and the treatment should be repeated if the ova are
still present. The worms are not always easy to destroy. Male-fern may be
given in doses of from a drachm to two drachms, followed by a saline purge.
The general treatment is that of anaemia.
IV. FILARIASIS.
For a full discussion of the zoological relations of this important group,
see Stiles' article in my " System of Medicine,'.' Vol. I.
Under the general term Filaria sanguinis Jiominis three species of nema-
todes are included:
Filaria bancrofti, Cobold, 1877. This is the ordinary blood filaria. The
embryos are found in the peripheral circulation only during sleep or at night.
The mosquito is the intermediate host. The embryos measure 270 to 340 fi
long by 7 to 11 /I. broad ; tail pointed. The adult male measures 83 mm. long
by 0.407 mm. broad ; the tail forms two turns of a spiral. The adult female
measures 155 mm. long by 0.715 mm. broad; vulva 2.56 nun. from anterior
extremity; eggs 38 fi by 14 ju,. This is the species to which the haematochy-
luria and elephantiasis are attributed.
Filaria diurna, Manson, 1891. The larvs agree with the preceding,
except that Manson indicates the absence of granules in the axis of the body.
The worms occur in the peripheral circulation only during the day, or when
the patient stays awake. Manson suspects that the Filaria loa represents the
adult stage.
Filaria perstans, Manson, 1891. Only the embryos are known. These
are much smaller than the preceding — 200 yu long, posterior extremity obtuse,
anterior extremity with a sort of retractile rostellum.
Manson is inclined to regard the Filaria perstans as the cause of craw-
craw, a papillo-pustular skin eruption of the west coast of Africa, which is
probably the same as Nielly's dcrmatose parasitaire, the parasite of which was
called by Blanchard Rhahditis Nielhji. Manson has shown that in the blood
of the aboriginal Indians in British Guiana there are two forms of filarial
48 DISEASES DUE TO ANIMAL PARASITES.
embryos which differ somewhat from the ordinary types. Daniels and Ozzard
have shown the extraordinary prevalence of these parasites in the aborigines —
fully 58 per cent. Daniels has found the mature filariae in two subjects in the
upper part of the mesentery, near the pancreas and in the subpericardial fat.
The most important of these is the Filaria Bancrofti, which produces the
haematochyluria and the lymph-scrotum.
The female produces an extraordinary number of embryos, which enter the
blood current through the lymphatics. Each embryo is within its shell, which
is elongated, scarcely perceptible, and in no way impedes the movements.
They are about the ninetieth part of an inch in length and the diameter of
a red blood-corpuscle in thickness, so that they readily pass through the
capillaries. They move with the greatest activity, and form very striking and
readily recognized objects in a blood-drop under the microscope. A remark-
able feature is the periodicity in the occurrence of the embryos in the blood.
In the daytime they are almost or entirely absent, whereas at night, in typical
cases, they are present in large numbers. If, however, as Stephen Mackenzie
has shown, the patient, reversing his habits, sleeps during the daj^, the peri-
odicity is reversed. In the case reported by Lothrop and Pratt the number
of embryos per cubic centimetre of blood was calculated hourly during
the night; it rose steadily from four o'clock in the afternoon till midnight,
when 3,100 per c.cm. were present, then fell, none being found at ten o'clock
the following morning. The further development of the embryos is associated
with the mosquito, which at night sucks the blood and in this way frees them
from the body. After developing a little it was thought that they were set
free in the water by the death of the host. S. P. James has found them in
the tissues of the proboscis of the mosquito, and the infection is probably
direct, as in malaria. The filariae may be present in the body without causing
any symptoms. In the blood of animals filariee are very common and rarely
cause inconvenience. It is only when the adult worms or the ova block the
lymph channels that certain definite symptoms occur, Manson suggests that
it is the ova (prematurely discharged), which are considerably shorter and
thicker than the full-grown embryos, which block the lymph channels and pro-
duce the conditions of haematochyluria, elephantiasis, and lymph-scrotum.
The parasite is widely distributed, particularly in tropical and subtropical
countries. Guiteras has shown that the disease prevails extensively in the
Southern States, and since his paper appeared contributions have been made
by Matas, of New Orleans, Mastin, of Mobile, De'Saussure, of Charleston,
and Opie.
The effects produced may be described under the following conditions:
1. H^MATOCHYLURiA. — Without any external manifestations, and in
many cases without special disturbance of health, the subject from time to
time passes urine of an opaque white, milky appearance, or bloody, or a chy-
lous fiuid which on settling shows a slightly reddish clot. The urine may be
normal in quantity or increased. The condition is usually intermittent, and
the patient may pass normal urine for weeks or months at a time. Micro-
scopically, the chylous urine contains minute molecular fat granules, usually
red blood-corpuscles in various amounts. The embryos were first discovered
by Demarquay, at Paris (1863), and in the urine by Wucherer, at Bahia, in
1866. It is remarkable for how long the condition may persist without seri-
. DISEASES CAUSED BY NEMATODES. 49
ous impairment of the health. A patient, sent to me by Dawson, of Charles-
ton, has had hsematochyluria intermittently for eighteen years. The only
inconvenience has been in the passage of the blood-clots which collect in the
bladder. At times he has also uneasy sensations in the lumbar region. The
embryos are present in his blood at night in large numbers. Chyluria is not
always due to, the filaria. The non-parasitic form of the disease is considered
elsewhere.
Opportunities for studying the anatomical condition of these cases rarely
occur. In the case described by Stephen Mackenzie the renal and peritoneal
lymph plexuses were enormously enlarged, extending from the diaphragm to
the pelvis. The thoracic duct above the diaphragm was impervious.
2. Lymph-Scrotum and certain forms of elephantiasis are also caused
by the filaria. In the former the tissues of the scrotum are enormously
thickened and the distended lymph-vessels may be plainly seen. A clear,
sometimes a turbid, fluid follows puncture of the skin. The question of the
relation of filarise to the forms of tropical elephantiasis has been reopened,
and it seems doubtful if all depend upon filarise.
Treatment. — So far as I know, no drug destroys the embryos in the blood.
In infected districts the drinking-water should be boiled or filtered. In
cases of chyluria the patients should use a dry diet and avoid all excess of
fat. The chyle may disappear quite rapidly from the urine under these meas-
ures, but it does not necessarily indicate that the case is cured. So long as
clots and albumin are present the leak in the lymphoid varix is not healed,
although the fat, not being supplied to the chyle, may not be present. A
single tumblerful of milk will at once give ocular proof of the patency or
otherwise of the rupture in the varix (Manson).
The surgical treatment of some of these cases is most successful, particu-
larly in the removal of the adult filarise from the enlarged lymph-glands,
especially in the groin. Maitland states that during seven years 25 opera-
tions of this kind have been performed without serious symptoms. In a
case of Primrose's, of Toronto, the parasites were absent from the blood six
and a half months after operation.
V. DRACONTIASIS (Guinea-worm Disease).
The Filaria or Dracunculus medinensis is a widely spread parasite in
parts of Africa and the East Indies. In the United States instances occa-
sionally occur. Jarvis reports a case in a post chaplain who had lived at
Fortress Monroe, Va., for thirty years. Van Harlingen's patient, a man
aged forty-seven, had never lived out of Philadelphia, so that the worm
must be included among the parasites of this country. A majority of the
cases reported in American journals have been imported.
Only the female is known. It develops in the subcutaneous and inter-
muscular connective tissues and produces vesicles and abscesses. In the
large majority of the cases the parasite is found in the leg. Of 181 cases,
in 124 the worm was found in the feet, 33 times in the leg, and 11 times in
the thigh. It is usually solitary, though there are cases on record in which
six or more have been present. It is cylindrical in form, about 2 mm. in
diameter, and from 50 to 80 cm. in length.
50 DISEASES DUE TO ANIMAL PARASITES.
The worm gains entrance to the system through the stomach, not through
the skin, as was formerly supposed. It is probable that both male and
female are ingested; but the former dies and is discharged, while the latter
after impregnation penetrates the intestine and attains its full development
in the subcutaneous tissues, where it may remain quiescent for a long time
and can be felt beneath the skin like a bundle of string. The worm con-
tains an enormous number of living embryos, and to enable them to escape
she travels slowly downward head first, and, as mentioned, usually reaches
the foot or ankle. The head then penetrates the skin and the epidermis
forms a little vesicle, which ruptures, and a small ulcer is left, at the bottom
of which the head often protrudes. The distended uterus ruptures and
the embryos are discharged in a whitish fluid. After getting rid of them
the worm will spontaneously leave her host. In the water the embryos
develop in the cyclops — a small crustacean — and it seems likely that man
is infected by drinking the water containing these developed larvae.
When the worm first appears it should not be disturbed, as after par-
turition she may leave spontaneously. When the worm begins to come out
a common procedure is to roll it round a portion of smooth wood and in
this way prevent the retraction, and each day wind a little more until the
entire worm is withdrawn. It is stated that special care must be taken to
prevent tearing of the worm, as disastrous consequences sometimes follow,
probably from the irritation caused by the migration of the embryos.
The parasite may be excised entire, or killed by injections of bichloride
of mercury (1 to 1,000). It is stated that the leaves of the plant called
amarpattee are almost a specific in the disease. Asafcetida in full doses is
said to kill the worm.
In East Africa Kolb states that he found in the abdominal cavity of
a recently killed native Massai several large nematode worms believed to
be allied to the filaria medinensis. He thinks this parasite is possibly asso-
ciated with what is known as the Massai disease, characterized by attacks of
fever lasting some three days, with tenderness of the abdomen and vomit-
ing. Kolb thinks that in these cases the filariae which have become encysted
about the liver " as a normal event in their life history burst their cysts, the
contents escaping into the peritoneal cavity, thereby giving rise to the symp-
toms." The subject is one which requires further investigation.
VI. OTHER NEMATODES.
Filariae. — Among less important filarian worms parasitic in man the
following may be mentioned : Filaria loa, which is a cylindrical worm of
about 3 cm. in length and whose habitat is beneath the conjunctiva. It has
been found on the West African coast, in Brazil, and in the West Indies.
Filaria lentis, which has been found in a cataract. Three specimens have
been found together. Filaria lahialis, which has been found in a pustule
in the upper lip. Filaria liominis oris, which was described by Leidy, from
the mouth of a child. Filaria hroncliialis, which has been found occasion-
ally in the trachea and bronchi. This parasite has been seen in a few
cases in the bronchioles and in the lungs. There is no evidence that it ever
produces an extensive verminous bronchitis similar to that which I haye
DISEASES CAUSED BY NEMATODES. 51
described in dogs. Filaria i7nmitis — the common Filaria sanguinis of the
dog — of which Bowlby has described two cases in man. In one case with
haeraaturia female worms were found in the portal vein, and the ova were
present in the thickened bladder wall and in the ureters.
Trichocephalus dispar (Whip- worm). — This parasite is not infrequently
found in the csecum and large intestine of man. It measures from 4 to 5 cm.
in length, the male being somewhat shorter than the female. The worm is
readily recognized by the remarkable difference between the anterior and
posterior portions. The former, which forms at least three fifths of the
body, is extremely thin and hair-like in contrast to the thick hinder por-
tion of the body, which in the female is conical and pointed, and in the
male more obtuse and usually rolled like a spring. The eggs are oval, lemon-
shaped, 0.05 mm. in length, and each is provided with a button-like pro-
jection.
The number of the worms found is variable, as many as a thousand hav-
ing been counted. It is a widely spread parasite. In parts of Europe it
occurs in from 10 to 30 per cent of all bodies examined, but in the United
States it is not so common. The trichocephalus rarely causes symptoms.
French and Boycott found ova in 40 of 500 Guy's Hospital patients. They
found no etiological relationship of the parasite to appendicitis. Several cases
have been reported in which profound anaemia has occurred in connection
with this parasite, usually with diarrhoea. Enormous numbers may be pres-
ent, as in Eudolph's case, without producing any symptoms.
The diagnosis is readily made by the examination of the faeces, which con-
tain, sometimes in great abundance, the characteristic lemon-shaped, hard,
dark-brown eggs.
Dicotophyme gigas (Eustrongylus gigas). — This enormous nematode,
the male of which measures about a foot in length and the female about
three feet, occurs in very many animals and has occasionally been met with
in man. It is usually found in the renal region and may entirely destroy
the kidney.
Anguillula aceti. — The Anguillula aceti, or vinegar eel, is sometimes
present in the urine (in one case it is said from the bladder). It is most
probably a contamination from a dirty bottle in which the urine is col-
lected.
Strongyloides intestinalis. — ^Under this name are now included the small
nematode worms found in the faeces and formerly described as Anguillula
stercoralis, Anguillula intestinalis, and Rhahdonema intestinale. This para-
site occurs abundantly in the stools of the endemic diarrhoea of hot countries,
and has been specially described by the French in the diarrhoea of Cochin-
China. It has been found in Manila by Strong, and three cases have been
reported from my clinic by W. S. Thayer. It is stated that the worms occupy
all parts of the intestines, and have even been found in the biliary and pan-
creatic duets. It is only when they are in very large numbers that they pro-
duce severe diarrhoea and anaemia.
Acanthocephala (Thorn-headed Worms). — The Gigantorhynchus or
Echinorhynclius gigas is a common parasite in the intestine of the hog and
attains a large size. The larvae develop in cockchafer grubs. The Ameri-
can intermediate host is the June bug (Stiles). Lambl found a small
52 DISEASES DUE TO ANIMAL PARASITES.
Echinorhynclius in the intestine of a boy. Welch's specimen, which was
found encysted in the intestine of a soldier at Netley, is stated by Cobbold
probably not to have been an Echinorhynclius. Eecently a case of Echino-
rhynchus moniliformis has been described in Italy by Grassi and Calandruccio.
F. PARASITIC ARACHNIDA AND TICKS.
Pentastomes. — 1. Lixguatula ehinaria {Pentastoma tcenioides) has a
somewhat lancet-shaped body, the female being from 3 to 4 inches in length,
the male about an inch in length. The body is tapering and marked by
numerous rings. The adult worm infests the frontal sinuses and nostrils
of the dog, more rarely of the horse. The larval form, which is known as
the Linguatula serrata {Pentastomum denticulatum) , is seen in the internal
organs, particularly the liver, but has also been found in the kidney. The
adult worm has been f OTind in the nostril of man, but is very rare and seldom
occasions any inconvenience. The larvae are by no means uncommon, par-
ticularly in parts of Germany.
2. The Poeocephalus con"STRICTUS (Pentastomum constrictum), which is
about the length of half an inch, with twenty-three rings on the abdomen,
was found by Aitken in the liver and lungs of a soldier of a West Indian
regiment.
The parasite is very rare. Flint refers to a Missouri case in which from
75 to 100 of the parasites were expectorated. The liver was enlarged and
the parasites probably occupied this region. In 1869 I saw a specimen which
had been passed with the urine by a patient of James H. Eichardson, of
Toronto.
Demodex (Acarus) folliculomni (var. hominis). — A minute parasite, from
0.3 mm. to 0.4 mm. in length, which lives in the sebaceous follicles, particu-
larly of the face. It is doubtful whether it produces any s5anptoms. Pos-
sibly when in large numbers they may excite inflammation of the follicles,
leading to acne.
Sarcoptes (Acarus) scabiei (Itch Insect). — This is the most important
of the arachnid parasites, as it produces troublesome and distressing skin
eruptions. The male is 0.23 mm. in length and 0.19 mm. in breadth; the
female is 0.45 mm. in length and 0.35 mm. in width. The female can be
seen readily with the naked eye and has a pearly-white color. It is not so
common a parasite in the United States and Canada as in Europe.
The insect lives in a small burrow, about 1 cm. in length, which it makes
for itself in the epidermis. At the end of this burrow the female lives.
The male is seldom found. The chief seat of the parasite is in the folds
where the skin is most delicate, as in the web between the fingers and toes,
the backs of the hands, the axilla, and the front of the abdomen. The head
and face are rarely involved. The lesions which result from the presence
of the itch insect are very numerous and result largely from the irritation
of the scratching. The commonest is a papular and vesicular rash, or, in
children, an ecthymatous eruption. The irritation and pustulation which
follow the scratching may completely destroy the burrows, but in typical
cases there is rarely doubt as to the diagnosis.
PARASITIC INSECTS. 53
The treatment is simple. It should consist of warm haths with a thor-
ough use of a soft soap, after which the skin should be anointed with sul-
phur ointment, which in the case of children should be diluted. An oint-
ment of naphthol (drachm to the ounce) is very efficacious.
Leptus autumnalis (Harvest Bug). — This reddish-colored parasite, about
half a millimetre in size, is often found in large numbers in fields and in
gardens. They attach themselves to animals and man with their sharp
proboscides, and the hooklets of their legs produce a great deal of irritation.
They are most frequently found on the legs. They are readily destroyed by
sulphur ointment or corrosive-sublimate lotions.
Ixodiasis (Tick-fever). — In South Africa, particularly in the western
provinces of the Uganda Protectorate, the western districts of German East
Africa and the eastern regions of the Congo Free State, there is a disease
known by this name, believed to be transmitted by a tick — the Ornithodorus
or Argas moubata. Christy states that the bite of the 0. Savignyi does not
produce any ill effects. The ticks live in old houses, and their habits are
very much like those of the common bedbug. The symptoms are pains in
the head, back and limbs, vomiting, fever and diarrhoea, which may last for
from two to four weeks. Death may occur between the tenth and fifteenth
days. A majority of the cases recover. A spirillum has been described in
the blood by P. H, Eoss and Milne.
The Dermacentor occidentaUs is present in the Northwestern States from
California to Montana. The bites may cause severe lymphangitis. It appears
to be the medium of transmission of the Eocky Mountain spotted fever, which
is described on p. 368.
In Arizona and other parts of the Southwestern States, a tick — Ornitho-
dorus megnini — is occasionally found in the ear and in the nose, causing
suppuration and intense suffering.
Several other varieties of ticks are occasionally found on man — ^the Ixodes
ricinus and the Dermacentor Americanus, which are met with in horses
and oxen.
G. PARASITIC INSECTS.
Pediculi (Phthiriasis; Pediculosis). — There are three varieties of the
body louse, which are found only in persons of uncleanly habits.
Pediculus capitis. — The male is from 1 to 1.5 mm. in length and the
female nearly 3 mm. The color varies somewhat with the different races
of men. It is light gray with a black margin in the European, and very
much darker in the negro and Chinese. They are oviparous, and the
female lays about sixty eggs, which mature in a week. The ova are
attached to the hairs, and can be readily seen as white specks, known
popularly as nits. The symptoms are irritation and itching of the scalp.
When numerous, the insects may excite an eczema or a pustular derma-
titis, which causes crusts and scabs, particularly at the back of the head.
In the most extreme cases the hair becomes tangled in these crusts and
matted together, forming at the occiput a firm mass which is known as
plica polonica, as it was not infrequent among the Jewish inhabitants of
Poland.
54 DISEASES DUE TO AXLMAL PARASITES.
Pediculus coepoeis (vestimentorum) . — Tliis is considerably larger than
the head louse. It lives on the clothing, and in sucking the blood causes
minute hsemorrhagic specks, which are very common about the neck, back,
and abdomen. The irritation of the bites may cause urticaria, and the
scratching is usually in linear lines. In long-standing cases, particularly
in old dissipated characters, the skin becomes rough and greatly pigmented,
a condition which has been termed the vagabond's disease — morbus erronum
— and which may be mistaken for the bronzing of Addison's disease. The
pigmentation in some cases may be extreme and extend to the face and
buccal mucosa.
Phthieius pubis differs somewhat from the other forms, and is found
in the parts of the body covered with short hairs, as the pubes ; more rarely
the axilla and eyebrows.
The taclies hJeuatres or peliomata, excited by the irritation of pediculi, are
peculiar subcuticular bluish or slate-colored spots from 5 to 10 mm, in diam-
eter seen about the abdomen and thighs, particularly in febrile cases. They
are very well pictured in Murchison's work on Fevers. The spots are more
marked on white thin skins. They are stains caused by a pigment in the
secretion of the salivary glands of the louse. I have never seen these macuIcB
ceruJecE, as they are also called, without finding the lice or their nits.
Treatment. — For the Pediculus capitis, when the condition is very bad,
the hair should be cut short, as it is very difficult to destroy thoroughly all
the nits. Eepeated saturations of the hair in coal-oil or in turpentine are
usually efficacious, or with lotions of carbolic acid, 1 to 50. Scrupulous
cleanliness and care are sufficient to prevent recurrence. In the case of the
Pediculus corporis, the clothing should be placed for hours in a disinfecting
oven. To allay the itching a warm bath containing 4 or 5 ounces of bicar-
bonate of soda is useful. The skin may be rubbed with a lotion of carbolic
acid, 2 drachms to the pint, with 2 ounces of glycerin. For the Phthirius
pubis wliite precipitate or ordinary mercurial ointment should be used, and
the parts should he thoroughly washed two or three times a day with soft soap
and water.
Cimex lectularius (Common Bedbug). — The tropical and subtropical
variety is Cimex rotundalius (W. S. Patton). It lives in the crevices of the
bedstead and in the cracks in the floor and in the walls. It is nocturnal in
its habits. The peculiar odor of the insect is caused by the secretion of a
special gland. The parasite possesses a long proboscis, with which it sucks
the blood. Individuals differ remarkably in the reaction to the bite of this
insect: some are not disturbed in the slightest by them, in others the irrita-
tion causes hyperemia and often intense urticaria. Fumigation with sul-
phur or scouring with corrosive-sublimate solution or kerosene destroys them.
Iron bedsteads should be used.
Pulex irritans (Commox Flea). — The male is from 2 to 2.5 mm. in
length, the female from 3 to 4 mm. The flea is a transient parasite on
man. The bite causes a circular red spot of hyperemia in the centre of
which is a little speck where the boring apparatus has entered. The amount
of irritation caused by the bite is variable. Many persons suffer intensely
and a diffuse erythema or an irritable urticaria develops; others suffer no
inconvenience whatever.
PARASITIC FLIES. 55
The Pulex penetrans (sand-flea; jigger) is found in tropical countries,
particularly in the West Indies and South America. It is much smaller
than the common flea, aud not only penetrates the skin, but burrows and
produces an inflammation with' pustular or vesicular swelling. It most fre-
quently attacks the feet. It is readily removed with a needle. Where they
exist in large numbers the essential oils are used on the feet as a preventive.
H. PARASITIC FLIES.
MYIASIS (Myiosis).
The accidental invasion of the body cavities and of the skin by the larvag
of the diptera is known as myiasis.
The larvae of the Lucilia macellaria, the so-called screw-worm, have been
found in the nose, in wounds, and in the vagina after delivery. They can
be removed readily with the forceps ; if there is any difficulty, thorough
cleansing and the application of an antiseptic bandage is sufficient to kill
them. The ova of the blue-bottle fly may be deposited in the nostrils, the
ears, or the conjunctiva — the myiasis narium, aurium, conjunctivEe. This
invasion rarely takes place unless these regions are the seat of the disease.
In the nose and in the ear the larvae may cause serious inflammation. Even
the urethra has not been spared in these dipterous invasions.
Gastro-intestinal myiasis may result from the swallowing of the larvae of
the common house-fly or of species of the genus Antliomyia. There are many
cases on record in which the larvge of the Musca domestica have been dis-
charged by vomiting. Instances in which dipterous larvae have been passed
in the fseces are less common. Finlayson, of Glasgow, has reported an inter-
esting ease in a physician, who, after protracted constipation and pain in
the back and sides, passed large numbers of the larvae of the flower-fly —
Antliomyia canicularis. Among other forms of larvae or gentles, as they are
sometimes called, which have been found in the faeces, are those of the com-
mon house-fly, the blue-bottle fly, and the Techomyza fusca. The larvae of
other insects are extremely rare. It is stated that the caterpillar of the
taby moth has been found in the faeces.
A specimen of the Homalomyia scalaris, one of the privy flies, was sent
to me by Dr. Hartin, of Kaslo City, British Columbia, the larvee of which
were passed in large numbers in the stools of a man aged twenty-four, a
native of Louisiana. They Were present in the stools from May 1 to July
15, 1897.
Although no grave results necessarily follow the invasion of the alimen-
tary tract by these larvae, yet they may be the cause of serious intestinal ulcer-
ation manifesting itself by a dysenteric disease with fatal result.
Cutaneous Myiasis. — The most common form of cutaneous myiasis is that
in which an external wound becomes " living," as it is called. This myiasis
vulnerum is caused by the larvae of either the blue-bottle or the common
flesh-fly.
The skin may also be infected by the larvae of the Musca vomitoria, but
more commonly by the bot-flies of the ox and sheep which occasionally attack
man. This condition is rare in temperate climates. Matas has described a
56 DISEASES DUE TO ANIMAL PARASITES.
case in which oestrus larvse were found in the gluteal region. In parts of
Central America the eggs of another bot-fly, the Dermatobia, are not infre-
quently deposited in the skin and produce a swelling very like the ordi-
nary boil.
Dermamyiasis linearis migrans CEstrosa is a remarkable cutaneous condi-
tion, observed particularly in Eussia and occasionally in other countries, in
which the larva of GastropMlus equi (Samson), the horse bot-fly, makes a
slightly raised pale red " line " which travels over the body surface, sometimes
with great rapidity. It has been referred to as Larva migrans and as Creep-
ing Eruption. (See Hamburger, Journal of Cutaneous Disease.s, 1904.)
In Africa the larvas of the Cayor fly are not uncommonly found beneath
the skin in little boils. In the Congo region. Button, Todd, and Christy
found a troublesome blood-sucking dipterous larva, known as the floor maggot,
the fly of which is the Anclimeromyia luteola.
Caterpillar Bash. — In some districts in Europe the hairs of the proces-
sion caterpillar, particularly of the species Cnethocampa, cause an intense
urticaria, the so-called U. epidemica. There are districts in Switzerland
which have been rendered uninhabitable in consequence of the skin rashes
caused by the caterpillars. Of late years in New England and some other
parts of the United States the caterpillar of the brown-tailed moth has caused
much discomfort. The hairs are widely distributed by the wind, and the barbs
are so arranged that they readily work into the skin. Wliole families have
been affected by an intense eruption which has been mistaken for that of
small-pox. In England, Thresh has called attention to the frequency of these
caterpillar rashes due to the yellow-tailed moth, Portkesia similis.
Harvest Rash (Erythema Autumxale). — In parts of England during
the autumn many people are attacked by the harvest bug or harvesters, which
may cause a very obstinate and distressing malady. Usually attributed to
the harvest spider, it is in reality caused by a mite, parasitic upon it, the
hexapod larva of the silky trombidian. It is so small as to be scarcely visible
and is brick-red in color. They chiefly attack persons with delicate skins
on the ankles and legs, but they may also attack the arms and the neck.
The mite attaches itself to the skin by its claws, sucks the blood, and the
swollen red abdomen may sometimes be seen as a bright-red dot. A papulo-
vesicular, sometimes a pustular eruption is caused by it with an intolerable
itching. So intense may the eruption be, with perhaps an entire family
attacked at once,, that suspicion of poisoning may be aroused. The parasite
is readily killed by benzine.
SECTION 11.
SPECIFIC II^FECTIOUS DISEASES.
I. TYPHOID FEVER.
Definition. — A general infection caused by bacillus typhosus, character-
ized anatomically by hyperplasia and ulceration of the intestinal lymph-folli-
cles, swelling of the mesenteric glands and spleen, and parenchymatous
changes in the other organs. There are cases in which the local changes are
slight or absent, and there are others with intense localization of the poison
in the lungs, spleen, kidneys, or cerebro-spinal system. Clinically the disease
is marked by fever, a rose-colored eruption, diarrhoea, abdominal tenderness,
tympanites, and enlargement of the spleen ; but these symptoms are extremely
inconstant, and even the fever varies in its character.
Historical Note. — Huxham, in his remarkable Essay on Fevers, had
" taken notice of the very great difference there is between the putrid malig-
nant and the slow nervous fever." In 1813 Pierre Bretonneau, of Tours,
distinguished " dothienenterite " as a separate disease ; and Petit and Serres
described entero-mesenteric fever. In 1839 Louis' great work appeared, in
which the name " typhoid " was given to the fever. At this period typhoid
fever alone prevailed in Paris and many European cities, and it was univer-
sally believed to be identical with the continued fever of Great Britain, where
in reality typhoid and typhus coexisted. The intestinal lesion was regarded
as an accidental occurrence in the course of ordinary typhus. Louis' stu-
dents returning to their homes in different countries had opportunities for
studying the prevalent fevers in the thorough and systematic manner of their
master. Among these were certain young American physicians, to one of
whom, Gerhard, of Philadelphia, is due the great honor of having first
clearly laid down the differences between the two diseases. His papers in
the American Journal of the Medical Sciences, 1837, are the first which
give a full and satisfactory account of their clinical and anatomical distinc-
tions. The studies of James Jackson, Sr. and Jr., of Enoch Hale and of
George C. Shattuck, of Boston, and of Alfred Stille and Austin Flint made
the subject very familiar in American medicine. In 1842 Elisha Bartlett's
work appeared, in which, for the first time in a systematic treatise, typhoid
and typhus fever were separately considered with admirable clearness. In
Great Britain the recognition of the difference between the two diseases was
very slow, and was due largely to A. P. Stewart, and, finally, to the careful
studies of Jenner between 1849 and 1850.
Etiology. — Geneeal Prevalence. — Typhoid fever prevails especially in
temperate climates, in which it constitutes the most common continued fever,
57
58 SPECIFIC INFECTIOUS DISEASES.
Widely distributed throughout all parts of the world, it probably presents
eyerywhere the same essential characteristics, and is everywhere an index of
the sanitary intelligence of a community. Imperfect sewerage and contam-
inated water-supply are two special conditions favoring the distribution of
the bacilli; filth, overcrowding, and had ventilation are accessories in lower-
ing the resistance of the individuals exposed. While from an infected person
the disease may be spread by fingers, food, and flies.
In England and Wales in 1906 the disease was fatal to 3,169 persons, a
mortality of 92 per million of living persons. It destroys more lives in
proportion to population in towns than in the country. The rate was lower
ia 1906 than in any year but one since 1869. Compared with the quinquennial
average, there was a very marked reduction (Tatham).
In India the disease is very prevalent; no race or creed is exempt, and
80 per cent of the cases of continued fever lasting three weeks prove to
be enteric (L. Eogers),
In the United States typhoid fever continues to be disgracefully prevalent.
From 1900 to 1904 the death rate in the registration areas was 33.8 per 100,000.
It is estimated that from 35,000 to 40,000 persons die of it every year, so
that at a moderate estimate nearly one half million people are attacked an-
nually. It is more prevalent in country districts than in cities, and, as Fulton
has sho"«Ti, the propagation is largely from the country to the town. What is
needed both in Canada and the United States is a realization by the public
that certaia primary laws of health must be obeyed.
In Germany the larger cities have comparatively little tj^hoid fever.
The story of Hamburg, as told by Eeincke (Lancet, i, 1904), should be read
by all interested in the disease. During the past twenty-five years the death
rate from enteric in Prussia has been reduced from an average of over 6 to
less than 2 per 10,000 of the population. It is still very prevalent in some
of the country districts.
Typhoid fever has been one of the great scourges of the armies, and kills
and maims more than powder and shot. The story of the recent wars forms
a sad chapter in human inefficiency.
In the Spanish- American War the report of the Commission (Eeed,
Yauglian, and Shakespeare) shows that one fifth of the soldiers in the national
encampments had typhoid fever — among 107,973 men there were 20,738
cases, with 1,580 deaths. In 90 per cent of the volunteer regiments
the disease broke out within eight weeks after going into camp. In
the opinion of the Commission the most important factors were camp pollu-
tion, flies as carriers of contagion, and the contamination through the air in
the form of dust.
In the South African War the British army, 557,653 officers and men,
had 57,684 cases of enteric fever, with 8,225 deaths (Simpson), while only
7,582 men died of wounds received in battle. As in America, the disease was
essentially one of the standing camps; troops constantly on the move were
rarely much affected. While contaminated water was no doubt an important
factor, as it always is in camp pollution, yet certain of the conditions in Africa
were peculiar. Fjecal and urinary contamination must have been very com-
mon, as in the cooking, performed in the open air, sand " entered largely into
every article of food." As there was a perfect plague of flies, they were with-
TYPHOID FEVER. 59
out doubt a very important factor in the infection of both food and drink.
On the other hand, the Japanese and Kussian War demonstrated the re-
markable efficiency of modern hygiene, if carried out in an intelligent man-
ner. The Japanese returns are not yet published, but no great war has ever
been conducted with such forethought for the preservation of the fighting
unit, and in consequence the mortality from typhoid fever and dysentery was
exceptionally low.
Season. — Almost without exception the disease is everywhere more preva-
lent in the autumn, hence the old popular name autumnal fever. The exhaust-
ive study of this question by Sedgwick and Winslow shows everywhere a strik-
ing parallelism between the monthly variations in temperature and the
prevalence of the disease. In a few cities, notably Paris, Philadelphia, Chi-
cago, and Dresden, the curves are irregular, showing, in addition to the usual
summer rise, two secondary maxima in the winter and spring, and these
authors suggest that epidemics at these seasons are characteristic of cities
whose water-supply is most subject to pollution. In their opinion " the most
reasonable explanation of the seasonal variations of typhoid fever is a direct
effect of the temperature upon the persistence in nature of the germs which
proceed from previous victims of the disease."
Of 1,500 cases at the Johns Hopkins Hospital (upon the study of which
this section is based), 840 were in August, September, and October.
Sex. — Males and females are equally liable to the disease, but males are
much more frequently admitted into hospitals, 2.4 to 1 in our series.
Age. — Typhoid fever is a disease of youth and early adult life. The
greatest susceptibility is between the ages of fifteen and twenty-five. Of
1,500 cases treated in my wards at the Johns Hopkins Hospital there were
under fifteen years of age, 231; between fifteen and twenty, 253; between
twenty and thirty, 680; between thirty and forty, 237; between forty and
fifty, 88; between fifty and sixty, 8; above sixty, 11; age not given, 1. Cases
are rare over sixty, although Manges believes that they are more common
than the records show. As the course is often atypical the diagnosis may be
uncertain and the disease not recognized until autopsy. It is not very infre-
quent in childhood, but infants are rarely attacked. Murchison saw a case
at the sixth month. There is no evidence that the disease is congenital even
in cases in which the mother has contracted it late in pregnancy.
Immunity. — Not all exposed to the infection take the disease. Some fam-
ilies seem more susceptible than others. One attack usually protects. Two
attacks have been described within a year. " Of 2,000 cases of enteric fever
at the Hamburg General Hospital, only 14 persons were affected twice and
only 1 person three times" (Dreschfeld). It is well known that usually
within a short time after recovery the immune substances disappear from the
blood, yet in most cases the relative immunity lasts a long time, frequently
for life. An experimental explanation for this fact has been given in the
demonstration that animals which have once reacted to the typhoid infec-
tion, react in throwing out immune substances more quickly and in larger
amounts when danger again threatens (Cole).
Bacillus typhosus. — The researches of Eberth, Koch, Gaffky, and others
have shown that there is a special micro-organism constantly associated with
typhoid fever, (a) General Characters. — It is a rather short, thick, flagel-
60 SPECIFIC INFECTIOUS DISEASES.
lated, motile bacillus, with rounded ends, in one of whicli, sometimes in both
(particularly in cultures), there can be seen a glistening round body, at one
time believed to be a spore; but these polar structures are probably only
areas of degenerated protoplasm. It grows readily on various nutritive media,
and can now be differentiated from Bacillus coli, with which, and with certain
other bacilli, it is apt to be confounded. This organism now fulfills all the
requirements of Koch's law — it is constantly present, and it grows outside the
body in a specific manner; the third requirement, the production of the
disease experimentally, has been successfully met by Griinbaum, of Leeds, who
has produced the disease in chimpanzees. The bacilli or their toxins inocu-
lated in large quantities into the blood of rabbits are pathogenic, and in
some instances ulcerative and necrotic lesions in the intestine may be pro-
duced. But similar intestinal lesions may be caused by other bacteria, includ-
ing Bacillus coli.
Cultures are killed within ten minutes by a temperature of 60° C. They
may live for eighteen weeks at — 5° C, although most die within two weeks,
and all within twenty-two weeks (Park). The typhoid bacillus resists ordi-
nary drying for months, unless in very thin layers, when it is killed in five
to fifteen days. The direct rays of the sun completely destroy them in from
four to ten hours' exposure. Bouillon cultures are destroyed by carbolic acid,
1 to 200, and by corrosive sublimate, 1 to 2,500.
(6) Distribution in the Body. — During recent years our ideas in regard
to the distribution of the typhoid bacilli have been much modified, owing to
the demonstration that in practically all cases the bacilli enter the circulat-
ing blood and are carried throughout the body. During life they may be
demonstrated in the circulating blood in a large proportion of cases, in
75 per cent of 604 collected cases (Coleman and Buxton). They occur in"
the urine in from 25 to 30 per cent of the cases. They may be isolated from
the stools in practically all cases at some stage. They are probably always
present in the rose spots. They are reported to have been cultivated from
the sweat, and they undoubtedly occur with considerable frequency in the
sputum (Eichardson, Rau, and others). At autopsy they are found widely
distributed, most numerous and constant usually in the mesenteric glands,
spleen, and gall-bladder, but are found in almost all organs, even the mus-
cles, uterus, and lungs (von Drigalski). Cultures made from the intestines
at autopsy (according to Jurgens, and also von Drigalski) show that they
are very few or can not be cultivated from the rectum up to the caecum, but
above this they increase in number, being very numerous in the duodenum
and jejunum, and practically constant in cultures made from the mucous
membrane of the stomach. They are also present in the oesophagus and
frequently on the tongue and tonsils. From endocardial vegetations, from
meningeal and pleural exudates and from foci of suppuration in various
parts of the body, the bacilli have also been isolated. A most important and
remarkable fact is that at times they may be present in the stools of persons
who show no symptoms of typhoid fever, but who have lived in very close asso-
ciation with typhoid-fever patients. This is especially true of children.
(c) The Bacilli Outside the Body. — In sterile water the bacilli retain
their vitality for weeks, but under ordinary conditions, in competition with
saprophytes, disappear within a few days. The question of the longevity of
TYPHOID FEVER. 61
the typhoid bacillus in water is of great importance, and has been much
discussed in connection with the supposed pollution of the waters of the Mis-
sissippi by the Chicago drainage canal. The experiments of E. 0. Jordan
would indicate that the vitality was retained as a rule not longer than three
days after infection. Whether an increase can occur in water is not finally
settled. Their detection in the water is difficult, and although they undoubt-
edly have been found, many such discoveries previously reported are not cer-
tain on account of the inaccurate differentiation of the typhoid bacillus and
varieties of the intestinal bacillus closely resembling it. Both Prudden and
Ernst have found it in water filters.
There are cities deriving their ice supply from polluted streams with
low death rates from typhoid fever. Sedgwick and Winslow conclude from
their careful study that very few typhoid germs survive in ice. The Ogdens-
burg epidemic in 1903-03 was apparently due to infection from ice.
Typhoid bacilli were grown from frozen material in it (Hutchins and
Wheeler).
In milh the bacilli undergo rapid development without changing its
appearance. They may persist for three months in sour milk, and may live
for several days in butter made from infected cream.
Eobertson has shown that under entirely natural conditions typhoid bacilli
may live in the upper layers of the soil for eleven months. Yon Drigalski
says if stools which contain typhoid bacilli are kept at room temperature the
B. typhosus disappears in a few days.
The direct infection by dust of exposed food-stuffs, such as milk, is very
probable. The bacilli retain their vitality for many weeks; in garden earth
twenty-one days, in filter-sand eighty-two days, in dust of the street thirty
days, on linen sixty to seventy days, on wood thirty-two days ; on thread kept
under suitable conditions for a year.
Modes OF Conveyance. — (a) Contagion. — Direct aerial transmission does
not seem probable. Each case should be regarded as a possible source of
infection, and in houses, hospitals, schools, and barracks a widespread epi-
demic may arise from it. Fingers, food, and flies are the chief means of
local propagation. It is impossible for a nurse to avoid finger contamination,
and without scrupulous care the germs may be widely distributed in a ward
or throughout a house. Cotton or rubber gloves are used in some institu-
tions. Even with special precautions and an unusually large proportion of
nurses to patients, we have not been able to avoid " house " infection at the
Johns Hopkins Hospital. T. B. Futcher has analyzed the 31 cases contracted
in the hospital among our first 1,500 cases; physicians, 5 * among a total of
288; nurses, 15 of a total of 407; patients, 8 out of a total of 47,956 admis-
sions; 4 of these occurred in a small ward epidemic. Two orderlies were
infected while caring for typhoid patients, and one woman in charge of a
supply room, where she only handled clean linen. Newman concludes from
his study of enteric in London that direct personal infection, and infection
through food are the two common channels for its propagation.
(&) Infection of water is the most common source of wide-spread epi-
demics, many of which have been shown to originate in the contamination
*Only three of these were in attendance on typhoid cases. Two of the five died — -
Oppenheimer and Ochsner.
62 • SPECIFIC INFECTIOUS DISEASES.
of a well or a spring. A very striking one occurred at Plymouth, Pa., in
1885, which was investigated by Shakespeare. The town, with a population
of 8,000, was in part supplied with drinking-water from a reservoir fed by
a mountain stream. During January, February, and March, in a cottage
by the side of and at a distance of from 60 to 80 feet from this stream, a
man was ill with typhoid fever. The attendants were in the habit at night
of throwing out the evacuations on the gi'ound toward the stream. During
these months the ground was frozen and covered with snow. In the latter
part of March and early in April there was considerable rainfall and a thaw,
in which a large part of the three months' accumulation of discharges was
washed into a brook, not 60 feet distant. At the very time of this thaw
the patient had numerous and copious discharges. About the 10th of April
cases of typhoid fever broke out in the town, appearing for a time at the
rate of fifty a day. In all about 1,200 people were attacked. An immense
majority of all the cases were in the part of the town which received water
from the infected reservoir.
The experience of Maidstone in 1897 illustrates the wide-spread and seri-
ous character of an epidemic when the Avater-supply becomes badly contami-
nated. The outbreak began about the middle of September, and within the
first two weeks 509 cases were reported. By October 27th there were 1,748
cases, and by November 17th 1,848 cases. In all, in a population of 35,000,
about 1,900 persons were attacked.
(c) Typhoid Carriers. — The bacilli may persist for years in the bile
passages and intestines of persons in good health. They have been found by
Young in the urinary bladder, and by Hunner in the gall-bladder, ten and
twenty years after the fever, and there have been cases of typhoid bone lesion
from which the bacilli were isolated many years after the primary attack.
Within the past few years the work of Strassburg observers has called attention
to a groujj of chronic typhoid carriers of the first importance in the spread
of the disease. One woman, a baker, had typhoid fever ten years previously.
The bacilli were found in large numbers in her stools. Every new employee
in the bakery sooner or later became seriously ill with typhoid-like symptoms,
and in two persons the disease proved fatal. Several localized epidemics have
been traced to these carriers, particularly in asylums, as determined by the
Strassburg observers. Ledingham, in one of the Scotch asylums at which
since 1893 small outbreaks of typhoid fever had occurred, reported 31 cases
with 9 fatal. Nothing abnormal could be determined in the water or in the
milk. Three typhoid carriers were detected. Soper reports an instance in
which a cook, apparently in perfect health, but in whose stools bacilli had
been present in large numbers, had been responsible for the occurrence of
typhoid in seven households in five years. Apparently there is no limit to
the length of time in which the bacilli may remain in the bile passages and
pass into the stools. Dean reports a case of a carrier of twenty-nine years'
standing, and instances of even longer duration are recorded.
(d) Infection of Food. — Milk may be the source of infection. One of
the most thoroughly studied epidemics due to this cause was that investigated
by Ballard in Islington. The milk may be contaminated by infected water
iised in cleaning the cans. The milk epidemics have been collected by Ernest
Hart and by Kober,
TYPHOID FEVER. 63
The germs may be conveyed in ice, salads of various sorts, etc. The
danger of eating celery and other uncooked vegetables, which have grown
in soil on which infected material has been used as a fertilizer;, must not
be forgotten.
Oysters. — Much attention has been paid of late years to the oyster as a
source of infection. In several epidemics, such as that in Middletown, ,
reported by Conn, that in Naples, by Lavis, and in the outbreak which
occurred at Winchester, the chain of circumstantial evidence seems com-
plete. Most suggestive sporadic cases have also been recorded by Broadbent
and others. Foote showed that oysters taken from the feeding-grounds in
rivers contain a larger number of micro-organisms of all sorts than those from
the sea. Chantemesse found typhoid bacilli in oysters which had lain in
infected sea-water, even after they had been transferred to and kept in fresh
water for a time. C. W. Field, working in the laboratories of the Department
of Health, New York (1904), confirms the observations of both Foote and
Chantemesse, but he could not determine that the bacilli were able to mul-
tiply within the oysters. Mosny, in his report to the French Glovernment
(1900), admits the possibility of oyster infection, but he thinks that the oyster
plays a very small role in relation to the total morbidity of the disease. Mus-
sels have also been found contaminated with typhoid bacilli, and it is stated
that dried fish have carried the infection.
(e) Flies. — The importance of flies in the transmission of the disease
was brought out very strongly in the Spanish-American War in 1898. The
Eeport of the Commission (Eeed, Vaughan, and Shakespeare) states that
" flies were undoubtedly the most active agents in the spread of typhoid fever.
Flies alternately visited and fed on the infected faecal matter and the food
in the mess-tent. . . . Typhoid fever was much less frequent among members
of messes who had their mess-tents screened than it was among those who
took no such precautions." In the South African War there was a perfect
plague of flies, particularly in the enteric fever tents, and among the army
surgeons the opinion was universal that they had a great deal to do with the
dissemination of the disease. Firth and Horrocks demonstrated the readi-
ness with which flies, after feeding on typhoid stools or fresh cultures of
typhoid bacilli, could infect sterile media. One of the most interesting
studies on the question was made in the Chicago epidemic of 1902 by Alice
Hamilton. Flies caught in two undrained privies, on the fences of two yards,
on the walls of two houses, and in the room of a typhoid-fever patient, were
used to inoculate eighteen tubes, and from five of these tubes typhoid bacilli
were isolated.
(/) Contamination of the Soil. — Filth, bad sewers, or cesspools can not
in themselves cause typhoid fever, but they furnish the conditions suitable
for the preservation of the bacillus, and possibly for its propagation.
Dust may be an important factor, though it has been shown that the
bacilli die very quickly when desiccated. In the dust storms during the South
African War the food was often covered with dust. Possibly, too, as Bar-
ringer suggests, the dust on the railway tracks may become contaminated.
Men working on the tracks are very liable to infection.
Modes of Infection. — While the bacillus has its primary seat of action
in the lymphatic tissues of the intestines, the fever is very largely due to
64 SPECIFIC INFECTIOUS DISEASES.
its growth in tlie internal organs. As Maclagan ybtj well puts it, the action
is dual, one a local specific action of the parasite on the glands of the intes-
tines, and a general action of the organism on the blood and tissues. A single
bacillus in ten days, as he says, might produce a billion, and the incubation
represents the period during which the bacilli are being reproduced.
We may recognize the following groups : 1. Ordinary typhoid fever with
marlced enteric lesions. An immense majority of all the cases are of this
character; and while the spleen and mesenteric glands are involved the lym-
phatic apparatus of the intestinal walls bears the brunt of the attack. 2.
Cases in ivhich the intestinal lesions are very slight, and may be found only
after a very careful search. In reviewing the cases of " tj'phoid fever with-
out intestinal lesions," Opie and Bassett call attention to the fact that in
many negative cases slight lesions really did exist, while in others death
occurred so late that the lesions might have healed. In some cases the
disease is a general septicemia with symptoms of severe intoxication and high
fever and delirium. In others the main lesions may be in organs — liver,
gall-bladder, pleura, meninges, or even the endocardium. 3. Cases in which
the typhoid hacillus enters the body without causing any lesion of the intes-
tine. In a number of the earlier cases reported as such the demonstration
of the typhoid bacillus was inconclusive. In others the intestine showed
tuberculous ulcers, through which the organisms may have entered. But
after excluding all these, a few cases remain in which the demonstration of
the typhoid bacillus was conclusive, cases in which death occurred early, and
yet after a very careful search no intestinal lesions could be found. There
were 4 cases in this series. Undoubtedly the intestinal lesions may be so
slight as not to be recognizable at autopsy. There is no conclusive evi-
dence that typhoid bacilli ever enter the body except through the intestinal
tract. 4. Mixed infections. It is well to distinguish, as Dreschfeld points
out, between double infections, as with bacillus tuberculosis, the diphtheria
bacillus, and the plasmodia of Laveran, in which two different diseases are
present and can be readily distinguished, and the true mixed or secondary
infections, in which the conditions induced by one organism favor the growth
of other pathogenic forms; thus in the ordinary typhoid-fever cases sec-
ondary infection with the colon bacillus, the streptococcus, staphylococcus,
or the pneumococcus, is quite conmion. 5. Para-typhoid infections. In
1898 GwjTi reported a remarkable case from my clinic, which presented all
of the clinical features of typhoid fever, but in which no serum reaction with
B. typhosus was present. From the blood of this patient he isolated in pure
culture a bacillus, differing from B. typhosus, but having properties inter-
mediate between B. typhosus and B. coli. This organism resembled one
which was isolated in 1897 by Widal from an oesophageal abscess, and which
he called a para-colon bacillus. In 1900 Gushing reported from the Johns
Hopkins Hospital the cultivation of a similar organism from a costo-chon-
dral abscess following an attack resembling typhoid fever. These organisms
belong in a group which also contains B. enteritidis, described as the cause
of meat poisoning, and also several varieties causing diseases in animals.
Since 1900, following the introduction of more accurate bacteriological
methods, similar organisms have been cultivated from numerous cases (now
many hundreds) clinically like mild typhoid. Enlargement of the spleen
TYPHOID FEVER. 65'
has been quite constantly present, while rose spots have been frequently seen,
and intestinal symptoms, even haemorrhages, have occurred, but perforation
has not been met with. Many cases have a very brief but acute course, re-
sembling food poisoning. The sequelae of ordinary typhoid fever may occur,
and the para-typhoid organism has been isolated from the lesions of osteo-
myelitis, an inflamed testis, and a chondrosternal abscess. In the ordinary
work of a medical clinic the cases are not very common. There were only 8 in
the last 500 cases in my series. There have been about 15 autopsies (Birt),
usually with enteric lesions. There is nothing in the clinical or anatomical
features to differentiate it from ordinary typhoid, and for practical pur-
poses they may be considered the same disease. The question is a bacterio-
logical one, and the diagnosis rests upon the cultural peculiarities of the
organism isolated from the blood or stools, and upon the agglutination tests.
6. Local infections. The typhoid bacillus may cause a local abscess, cystitis,
or cholecystitis without evidence of a general infection. 7. Terminal typhoid
infections. In rare instances the bacillus causes a fatal infection towards the
end of other diseases. The subjects may, of course, be typhoid carriers. In
two cases of malignant disease at the Johns Hopkins Hospital the bacilli
were isolated from the blood, and there were no intestinal lesions.
Products of the Growth of the Bacilli. — Brieger isolated from cultures
a poison belonging to the group of ptomaines — typhotoxin. Later he and
Fraenkel isolated a poison belonging to the group of toxalbumins. Accord-
ing to Pfeiffer, the chief poison belongs to the intracellular group of toxins.
Sidney Martin has isolated a poison which is in the nature of a secretion,
but does not differ from that contained within the bacterial cell. Injected
into animals it causes lowering of temperature, diarrhoea, loss of weight, and
degeneration of the myocardium. Its chemical nature is not known. Sim-
ilar, but weaker, poisons may also be isolated from cultures of Bacillus coli
and other members of this group. No toxins have yet been isolated which
cause changes in animals at all comparable to typhoid fever in human beings.
Macfadyen and Eowland, by mechanically breaking up the bacilli after they
had been frozen by means of liquid air obtained toxins, which injected into
monkeys had both antitoxic and antibacterial properties.
Morbid Anatomy. — Intestines. — A catarrhal condition exists through-
out the small and large bowel. Specific changes occur in the lymphoid ele-
ments, chiefly at the lower end of the ileum. The alterations which occur
are most conveniently described in four stages :
1. Hyperplasia, which involves the glands of Peyer in the jejunum and
ileum, and to a variable extent those in the large intestine. The follicles
are swollen, grayish-white, and the patches may project 3 to 5 mm., or may be
still more prominent. The solitary glands, which range in size from a pin's
head to a pea, are usually deeply imbedded in the submucosa, but project to
a variable extent. Occasionally they are very prominent, and may be almost
pedunculated. Microscopical examination shows at the outset a condition of
hyperaemia of the follicles. Later there is a great increase and accumula-
tion of cells of the lymph- tissue which may even infiltrate the adjacent
mucosa and the muscularis; and the blood-vessels are more or less com-
pressed, which gives the whitish, anaemic appearance to the follicles. The
cells have all the characters of ordinary lymph-corpuscles. Some of them,
6
66 SPECIFIC INFECTIOUS DISEASES.
however, are larger, epithelioid, and contain several nuclei. Occasionally
cells containing red blood-corpnscles are seen. This so-called medullary infil-
tration, which is always more intense toward the lower end of the ileum,
reaches its height from the eighth to the tenth day and then undergoes one
of two changes, resolution or necrosis. Death very rarely takes place at this
stage. Eesolution is accomplished by a fatty and granular change in the
cells, which are destroyed and absorbed. A curious condition of the patches
is produced at this stage, in which they have a reticulated appearance, the
plaques a surface reticulee. The swollen follicles in the patch undergo reso-
lution and shrink more rapidly than the surrounding framework, or what is
more probable the follicles alone, owing to the intense hyperplasia, become
necrotic and disintegrate, leaving the little pits. In this process superficial
hsemorrhages may result, and small ulcers may originate by the fusion of
these superficial losses of substance.
Except histologically there is nothing distinctive in the h}q3erplasia of the
lymph-follicles; but apart from enteric we rarely see in adults a marked
affection of these glands with fever. In children, however, it is not uncom-
mon when death has occurred from intestinal affections, and it is also met
with in measles, diphtheria, and scarlet fever.
2. Necrosis and Sloughing. — When the hyperplasia of the lymph-follicles
reaches a certain grade, resolution is no longer possible. The blood-vessels-
become choked, there is a condition of aneemic necrosis, and sloughs form
which must be separated and thrown off. The necrosis is probably due in
great part to the direct action of the bacilli. According to Mallory, there
occurs a proliferation of endothelial cells due to the action of a toxin. These
cells are phagocytic in character, and the swelling of the intestinal lymphoid
tissue is due almost entirely to their formation. The necrosis, he thinks,.
is due to the occlusion of the veins and capillaries by fibrinous thrombi, which
owe their origin to degeneration of phagocytic cells beneath the lining endo-
thelium of the vessels. The process may be superficial, affecting only the
upper part of the mucous coat, or it may extend to and involve the submu-
cosa. The " slough " may sometimes lie upon the Peyer's patch, scarcely
involving more than the epithelium (Marchand). It is always more intense
toward the ileo-cascal valve, and in very severe cases the greater part of the
mucosa of the last foot of the ileum may be converted into a brownish-black
eschar. The necrotic area in the solitary glands forms a yellowish cap
which often involves only the most prominent point of a follicle. The extent
of the necrosis is very variable. It may pass deep into the muscular coat,,
reaching to or even perforating the peritonaeum.
3. Ulceration. — The separation of the necrotic tissue — the sloughing —
is gradually effected from the edges inward, and results in the formation
of an ulcer, the size and extent of which are directly proportionate to the
amount of necrosis. If this be superficial, the entire thickness of the mucosa
may not be involved and the loss of substance may be small and shallow.
More commonly the slough in separating exposes the submucosa and mus-
cularis, particularly the latter, which forms the floor of a majority of all
typhoid ulcers. It is not common for an entire Peyer's patch to slough
away, and a perfectly ovoid ulcer opposite to the mesentery is rarely seen.
Irregularly oval and rounded forms are most common. A large patch may
TYPHOID FEVER. 67
present three or four ulcers divided by septa of mucous membrane. The
terminal 6 or 8 inches of the mucous membrane of the ileum may form a
large ulcer, in which are here and there islands of mucosa. The edges of
the ulcer are usually swollen, soft, sometimes congested, and often under-
mined. At a late period the ulcers near the valve may have very irregular
sinuous borders. The base of a typhoid ulcer is smooth and clean, being ,
usually formed of the submucosa or of the muscularis.
There may be large ulcers near the valve and swollen hypersemic patches
of Peyer in the upper part of the ileum.
4. Healing. — This begins with the development of a thin granulation
tissue which covers the base. Occasionally an appearance is seen as if an
ulcer had healed in one place and was extending in another. The mucosa
gradually extends from the edge, and a new growth of epithelium is formed.
The glandular elements are reformed ; the healed ulcer is somewhat depressed
and is usually pigmented. In death during relapse healing ulcers may be
seen in some patches with fresh ulcers in others.
We may say, indeed, that healing begins with the separation of the
sloughs, as, when resolution is impossible, the removal of the necrosed part
is the first step in the process of repair. In fatal cases, we seldom meet with
evidences of cicatrization, as the majority of deaths occur before this stage
is reached. It is remarkable that no matter how extensive the ulceration has
been, healing is never associated with stricture, and typhoid fever does not
appear as one of the causes of intestinal obstruction. Within a very short
time all traces of the old ulcers disappear.
Large Intestine. — The csecum and colon are affected in about one third
of the cases. Sometimes the solitary glands are greatly enlarged. The
ulcers are usually larger in the caecum than in the colon.
Perfoeation oe the Bowel. — Incidence at Autopsy. — J. A. Scott's
figures, embracing 9,713 cases from recent English, Canadian, and American
sources, give 351 deaths from perforation among 1,037 deaths from all
causes, a percentage of 33.8 of the deaths and 3.6 of the cases. The German
statistics give a much lower proportion of deaths from perforation; Munich
in 2,000 autopsies, 5.7 per cent from perforation; Basle in 2,000 autopsies,
1.3 per cent from perforation; Hamburg in 3,686 autopsies, 1.2 per cent
from perforation (Hector Mackenzie, Lancet, 1903). At the Johns Hopkins
Hospital among 1,500 cases of typhoid fever there were 43 with perforation.
Twenty of these were operated upon, with 7 recoveries. One other case died
of the toxaemia on the eighth day after operation. At the Pennsylvania Hos-
pital there were 50 cases of perforation among 1,948 cases. Chomel remarks
that " the accident is sometimes the result of ulceration, sometimes of a true
eschar, and sometimes it is produced by the distention of the intestine, caus-
ing the rupture of tissues weakened by disease." As a rule, sloughs are
adherent about the site of perforation. The site is usually in the ileum,
232 times in Hector Mackenzie's collection of 264 cases; the jejunum twice,
the large intestine 22 times, and the appendix 9 times in his series. As a
rule, the perforation occurs within twelve inches of the ileo-cffical valve.
There may be two or three separate perforations. J. A. Scott describes two
distinct varieties: first, the more common single, circular, pin-point in size,
due to the extension of a necrotic process through the base of a small ulcer.
68 SPECIFIC INFECTIOUS DISEASES.
The second variet}^, produced by a large area of tissue becoming necrotic,
ranges in size from the finger-tip to 3 cm. in diameter.
Death from hcemorrhage occurred in 99 of the Munich cases, and in 12
of 137 deaths in my 1,500 cases. The bleeding seems to result directly from
the separation of the sloughs. I was not able in any instance to find the
bleeding vessel. In one case only a single patch had sloughed, and a firm
clot was adherent to it. The bleeding may also come from the soft swollen
edges of the patch.
The mesenteric glands show hypergemia and subsequently become greatly
swollen. Spots of necrosis are common. In several of my cases suppuration
had occurred, and in one a large abscess of the mesentery was present. The
rupture of a softened or suppurating mesenteric gland, of which there are
only five or six cases in the literature, may cause either fatal hsemorrhage or
peritonitis. LeConte has successfully operated upon the latter condition. The
bunch of glands in the mesentery, at the lower end of the ileum, is especially
involved. The retroperitoneal glands are also swollen.
The spleen is invariably enlarged in the early stages of the disease. In
11 of my series it exceeded 20 ounces (600 grams) in weight, in one 900
grams. The tissue is soft, even diffluent. Infarction is not infrequent. Eup-
ture may occur spontaneously or as a result of injury. In the Munich autop-
sies there were 5 instances of rupture of the spleen, one of which resulted
from a gangrenous abscess.
The hone-marrow shows changes very similar to those in the lymphoid
tissues, and there may be foci of necrosis (Longcope).
The liver shows signs of parenchymatous degeneration. Early in the dis-
ease it is hypergemic, and in a majority of instances it is swollen, somewhat
pale, on section turbid, and microscopically the cells are very granular and
loaded with fat. Nodular areas (microscopic) occur in many cases, as
described by Hanford. Eeed, in Welch's laboratory, could not determiae
any relation between the groups of bacilli and these areas (Studies II). Some
of the nodules are lymphoid, others are necrotic. In 12 of the Munich autop-
sies liver abscess was found, and in 3, acute yellow atrophy. In 2 of this
series liver abscess occurred. Pyleplilebitis may follow abscess of the mesen-
tery or perforation of the appendix. Affections of the gall-bladder are not
uncommon, and are fully described under the clinical features.
Kidneys. — Cloudy swelling, with granular degeneration of the cells of
the convoluted tubules, less commonly an acute nephritis, may be present.
Eayer, Wagner, and others described the occurrence of numerous small areas
infiltrated with round cells, which may have the appearance of lymphomata,
or may pass on to softening and suppuration, producing the so-called miliary
abscesses, of which there were 7 cases in this series. The typhoid bacilli have
been found in these areas. They may also be found in the urine. The kid-
neys in cases of t}^hoid bacilluria may show no changes other than cloudy
swelling. Diphtheritic inflammation of the pelvis of the kidney may occur.
It was present in 3 of my cases, in one of which the tips of the papillae were
also affected. Catarrh of the bladder is not uncommon. Diphtheritic inflam-
mation of this viscus may also occur. Orchitis is occasionally met with.
Eespiratoet Organs. — Ulceration of the larjmx occurs in a certain num-
ber of cases; in the Munich series it was noted 107 times. It may come on
TYPHOID FEVER. 69
at the same time as the ulceration in the ileum. It occurs in the posterior
wall, at the insertion of the cords^ at the base of the epiglottis, and on the
ary-epiglottidean folds. The cartilages are very apt to become involved. In
the later periods catarrhal and diphtheritic ulcers may be present.
(Edema of the glottis was present in 20 of the Munich cases, in 8 of
which tracheotomy was performed. Diphtheritis of the pharynx and larynx
is not very uncommon. It occurred in a most extensive form in 2 of my
cases. Lobar pneumonia may be found early in the disease (see Pneumo-
TYPHUs), or it may be a late event. Hypostatic congestion and the con-
dition of the lung spoken of as splenization are very common. Gangrene
of the lung occurred in 40 cases in the Munich series; abscess of the lung
in 14; haemorrhagic infarction in 129. Pleurisy is not a very common event.
Fibrinous pleurisy occurred in about 6 per cent of the Munich cases, and
empyema in nearly 2 per cent.
Changes in the Circulatory System. — Heart Lesions. — Endocarditis,
while not a common complication, is probably more frequent than is generally
supposed. It was present without being suspected in three out of 101 autop-
sies in this series, while in three other cases of my series the clinical S5nnp-
toms suggested its presence. The typhoid bacilli have been found in the
vegetations. Pericarditis was present in 14 cases of the Munich autopsies.
Myocarditis is not very infrequent. In protracted cases the muscle-fibre is
usually soft, flabby, and of a pale yellowish-brown color. The softening may
be extreme, though rarely of the grade described by Stokes in typhus fever,
in which, when held apex up by the vessels, the organ collapsed over the hand,
forming a mushroom-like cap. Microscopically, the fibres may show little
or no change, even when the impulse of the heart has been extremely feeble.
A granular parenchymatous degeneration is common. Fatty degeneration
may be present, particularly in long-standing cases with ansemia. The
hyaline change is not common. The segmenting myocarditis, in which the
. cement substance is softened so that the muscles separate, has also been
found, but probably as a post-mortem change.
Lesions of the Blood-vessels. — Changes in the arteries are not infrequent.
In 21 of 52 cases in our series, in which there were notes on the state of the
aorta, fresh endarteritis was present, and in 13 of 62 cases in which the condi-
tion of the coronary arteries was noted similar changes were found (Thayer).
Arteritis of a peripheral vessel with thrombus formation is not uncom-
mon. Bacilli have been found in the thrombi. The artery may be blocked
by a thrombus of cardiac origin — an embolus — but in the great majority of
instances they are autochthonous and due to arteritis, obliterating or partial.
Thrombosis in the veins is very much more frequent than in the arteries, but
is not such a serious event. It is most frequent in the femoral, and in the
left more often than the right. The consequences are fully considered under
the symptoms.
ISTervgus System. — There are very few obvious changes met with. Men-
ingitis is extremely rare. It occurred in only 11 of the 2,000 Munich cases.
The exudation may be either serous, sero-fibrinous, or purulent, and typhoid
bacilli have been isolated. Five cases of serous and one of purulent menin-
gitis occurred in our series (Cole). Optic neuritis, which occurs sometimes
in typhoid fever, has not, so far as I know, been described in connection with
70 SPECIFIC INFECTIOUS DISEASES.
the meningitis. The anatomical lesion of the aphasia — seen not infrequently
in children — is not known, possibly it is an encephalitis. Parenchymatous
changes have been met with in the peripheral nerves, and appear to be not
very uncommon, even when there have been no symptoms of neuritis.
The voluntary muscles show, in certain instances, the changes described
by Zenker, which occur, however, in all long-standing febrile affections, and
are not peculiar to typhoid fever. The muscle substance within the sarco-
lemma undergoes either a granular degeneration or a hyaline transformation.
The abdominal muscles, the adductors of the thighs, and the pectorals are
most commonly involved. Eupture of a rectus abdominis has been found
post mortem. Hemorrhage may occur. Abscesses ma}^ develop in the mus-
cles during convalescence.
Symptoms. — In a disease so complex as typhoid fever it will be well first
to give a general description, and then to study more fully the symptoms,
complications, and sequelae according to the individual organs.
General Desceiption. — The period of incubation lasts from '' eight to
fourteen days, sometimes twenty- three " (Clinical Society), during which
there are feelings of lassitude and inaptitude for work. The onset is rarely
abrupt. In the 1,500 cases there occurred at onset chills in 334, headache in
1,117, anorexia in 825, diarrhoea (without purgation) in 516, epistaxis in
323, abdominal pain in 443, constipation in 349, pain in right iliac fossa
in 10. The patient at last takes to his bed, from which event, in a- majority
of cases, the definite onset of the disease may be dated. During the first
week there is, in some cases (but by no means in all, as has long been taught),
a steady rise in the fever, the evening record rising a degree or a degree and
a half higher each day, reaching 103° or 104°. The pulse is rapid, from 100
to 110, full in volume, but of low tension and often dicrotic; the tongue is
coated and white; the abdomen is slightly distended and tender. Unless the
fever is high there is no delirium, but the patient complains of headache, and
there may be mental confusion and wandering at night. The bowels may be
constipated, or there may be two or three loose movements daily. Toward
the end of the week the spleen becomes enlarged and the rash appears in the
form of rose-colored spots, seen first on the skin of the abdomen. Cough and
bronchitic symptoms are not uncommon at the outset.
In the second week, in cases of moderate severity, the symptoms become
aggravated; the fever remains high and the morning remission is slight.
The pulse is rapid and loses its dicrotic character. There is no longer head-
ache, but there are mental torpor and dulness. The face looks heavy; the
lips are dry; the tongue, in severe cases, becomes dry also. The abdominal
symptoms, if present — diarrhoea, tympanites, and tenderness — ^become aggra-
vated. Death may occur during this week, with pronounced nervous symp-
toms, or, toward the end of it, from haemorrhage or perforation. In mild
cases the temperature declines, and by the fourteenth day may be normal.
In the third week, in cases of moderate severity, the pulse ranges from
110 to 130; the temperature now shows marked morning remissions, and
there is a gradual decline in the fever. The loss of flesh is now more notice-
able, and the weakness is pronounced. Diarrhoea and meteorism may now
occur for the first time. Unfavorable symptoms at this stage are the pul-
monary complications, increasing feebleness of the heart, and pronounced
TYPHOID FEVER,- 71
delirium with muscular tremor. Special dangers are perforation and haem-
orrhage.
With the fourth week, in a majority of instances, convalescence begins.
The temperature gradually reaches the normal point, the diarrhoea stops,
the tongue cleans, and the desire for food returns. In severe cases the fourth
and even the fifth week may present an aggravated picture of the third ; the
patient grows weaker, the pulse is more rapid and feeble, the tongue dry, and
the abdomen distended. He lies in a condition of profound stupor, with low
muttering delirium and subsultus tendinum, and passes the fseces and urine
involuntarily. Heart-failure and secondary complications are the chief dan-
gers of this period.
In the fifth and sixth weeks protracted cases may still show irregular
fever, and convalescence may not set in until after the fortieth day. In this
period we meet with relapses in the milder forms or slight recrudescence of
the fever. At this time, too, occur many of the complications and sequelae.
Special Features and Symptoms. — Mode of Onset. — As a rule, the
symptoms come on insidiously, and the patient is unable to fix definitely
the time at which he began to feel ill. The following are the most important
deviations from this common course :
(a) Onset with Pronounced, sometimes Sudden, Nervous Manifestations.
— Headache, of a severe and intractable nature, is by no means an infrequent
initial symptom. Again, a severe facial neuralgia may for a few days put
the practitioner off his guard. In cases in which the patients have kept about
and, as they say, fought the disease, the very first manifestation may be pro-
nounced delirium. Such patients may even leave home and wander about
for days. In rare cases the disease sets in with the most intense cerebro-
spinal symptoms, simulating meningitis — severe headache, photophobia, re-
traction of the head, twitching of the muscles, and even convulsions. Occa-
sionally drowsiness, stupor, and signs of basilar meningitis may exist for ten
days or more before the characteristic symptoms develop; the onset may be
with mania.
(&) With Pronounced Pulmonary Symptoms. — The initial bronchial
catarrh may be of great severity and obscure the other features of the disease.
More striking still are those cases in which the disease sets in with a single
chill, with pain in the side and all the characteristic features of lobar pneu-
monia, or of acute pleurisy; or tuberculosis is suspected.
(c) With Intense Gastro-intestinal Symptoms. — The incessant vomiting
and pain may lead to a suspicion of poisoning, or the case may be sent to
the surgical wards for appendicitis.
(d) With symptoms of an acute nephritis, smoky or bloody urine, with
much albumin and tube-casts.
(e) Ambulatory Form. — Deserving of especial mention are those cases
of typhoid fever in which the patient keeps about and attempts to do work,
or perhaps takes a long journey to his home. He may come under observa-
tion for the first time with a temperature of 104° or 105°, and with the rash
well out. Many of these cases run a severe course, and in general hospitals
they contribute largely to the total mortality. Finally, there are rare in-
stances in which typhoid is unsuspected until perforation, or a profuse haem-
orrhage from the bowels occurs.
72 SPECIFIC INFECTIOUS DISEASES.-
Facial Aspect, — Early in the disease the cheeks are flushed and the eyes
bright. Toward the end of the first week the expression becomes more list-
less, and when the disease is well established the patient has a dull and heavy
look. There is never the rapid anaemia of malarial fever, and the color of the
lips and cheeks may be retained even to the third week.
Fever. — (a) Regular Course. (Chart II.) — In the stage of invasion the
fever rises steadily during the first five or six days. The evening temperature
is about a degree or a degree and a half higher than the morning remission,
so that a temperature of 104° or 105° is not uncommon by the end of the first
week. Having reached the fastigium or height, the fever then persists with
very slight daily remissions. The fever may be singularly persistent and
but little influenced by bathing or other measures. At the end of the second
and throughout the third week the temperature becomes more distinctly remit-
tent. The difference between the morning or evening record may be 3° or 4°,
and the morning temperature may even be normal. It falls by lysis, and the
temperature is not considered normal until the evening record is at 98.2°.
(6) Variations from the typical temperature curve are common. We do
not always see the gradual step-like ascent in the early stage; the cases do
not often come under observation at this time. When the disease sets in
with a chill, or in children with a convulsion, the temperature may rise at
once to 103° or 104°. In many cases defervescence occurs at the end of the
second week and the temperature may fall rapidly, reaching the normal
within twelve or twenty hours. An inverse type of temperature, high in the
morning and low in the evening, is occasionally seen but has no especial
significance.
Sudden falls in the temperature may occur; thus, as shown in Chart IV,
a drop of 6.4° may follow an intestinal haemorrhage, and the fall may be very
apparent even before the blood has appeared in the stools. Sometimes dur-
ing the anaemia which follows a severe hemorrhage from the bowels there are
remarkable oscillations in the temperature. Hyperpyrexia is rare. In only
58 of 1,500 cases did the fever rise above 106°. Before death the fever may
rise; the highest I have known was 109.5°.
(c) Post-typhoid Variations. (1) Recrudescences. — After a normal tem-
perature of perhaps five or six days, the fever may rise suddenly to 102° or
103°, without constitutional disturbance, furring of the tongue, or abdomi-
nal symptoms. After persisting for from two to four days the tempera-
ture falls. Of 1,500 cases, 92 presented these post-typhoid elevations, brief
notes of which are given in the Studies on Typhoid Fever. Constipation,
errors in diet, or excitement may cause them. These attacks are a frequent
source of anxiety to the practitioner. They are very common, and it is not
always possible to say upon what they depend. As a rule, if the rise in tem-
perature is the result of the onset of a complication, such as pleurisy or
thrombosis, there is an increase in the leucocytes. Naturally one suspects
at the outset a relapse, but there is an absence of the step-like ascent, and
as a rule the fever falls afte*- lasting a few days.
(2) The Suh-fehrile Stage of Convalescence. — In children, in very nerv-
ous patients, and in cases with anaemia, the evening temperature may keep
up for weeks after the tongue has cleaned and the appetite has returned.
This may usually be disregarded, and is often best treated by allowing the
TYPHOID FEVER.
73
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74 SPECIFIC INFECTIOUS DISEASES.
patient to get up, and by stopping the use of the thermometer. Of course
it is important not to overlook any latent complications.
(3) Hypothermia. — Low temperatures in typhoid fever are common,
following the tubs, or spontaneously in the third and fourth week in the
periods of marked remissions, and following haemorrhage. An interesting
form i€ the persistent hypothermia of convalescence. For ten days or more,
particularly in the protracted cases with great emaciation, the temperature
may be 96.5° or 97°. It is of no special significance.
{d) The Fever of the Relapse. — This is a repetition in many instances
of the original fever, a gradual ascent and maintenance for a few days at
a certain height and then a gradual decline. It is shorter than the original
pjTexia, and rarely continues more than two or three weeks. (Chart II.)
(e) Afebrile Typhoid. — There are cases described in which the chief fea-
tures of the disease have been present without the existence of fever. They
are extremely rare in this country. I have seen a case, afebrile at the thir-
teenth day, and in which the rose spots and other features persisted till the
twenty-eighth day.
(/) Chills occur (a) sometimes with the fever of onset; (&) occasion-
ally at intervals throughout the course of the disease, and followed by sweats
(so-called sudoral form) ; (c) with the advent of complications, pleurisy,
pneumonia, otitis media, periostitis, etc.; (d) with active antipyretic treat-
ment by the coal-tar remedies; (e) occasionally during the period of defer-
vescence without relation to any complication or sequel, probably due to a
septic infection; (/) according to Herringham, chills may result from con-
stipation. There are cases in which throughout the latter half of the disease
chills recur with great severity. (See Chills in Typhoid Fever, Studies II.)
Skin. — The characteristic rash of the disease consists of hj^ersemic spots,
which appear from the seventh to the tenth day, usually at first upon the
abdomen. They are slightly raised, flattened papules, which can be felt dis-
tinctly by the finger, of a rose-red color, disappearing on pressure, and rang-
ing in diameter from 2 to 4 mm. They were present in 93.3 per cent of the
white patients and 20.6 per cent of the colored. They come out in successive
crops, and after persisting for two or three days they disappear, occasionally
leaving a brownish stain. The spots may be present upon the back, and not
upon the abdomen. The eruption may be very abundant over the whole skin
of the trunk, and on the extremities. There were 81 in which they occurred
on the arms, IT on the forearms, 43 on the thighs, legs 15, face 5, hands 3.
The cases with very abundant eruption are not necessarily more severe. As
already noted, the t}^hoid bacilli have been found in the spots. Of variations
in the rash, frequently the spots are capped by small vesicles. Cases that
have not been carefully sponged ma}' show sweat vesicles, either miliary or
sudaminal. In 38 cases in my series there were purpuric spots. Three of
the cases were true hsemorrhagic typhoid fever. The rash may not appear
until the relapse. In 21 cases in our series the rose spots came out after the
patient was afebrile.
A branny desquamation is not rare in children, and common in adults
after hydrotherapy. Occasionally the skin peels off in large flakes.
Among other skin lesions in typhoid fever the following may be men-
tioned :
TYPHOID FEVER. 75
Erythema. — It is not very uncommon in the first week of the disease to
find a diffuse erythematous blush — E. typhosum. Formerly we thought this
might be due to quinine.
The tache cerebrale, a red line with white borders, is readily produced
by drawing the nail over the skin, a vaso-motor phenomenon of no special sig-
nificance. Sometimes the skin may have a peculiar mottled pink and white
appearance. E. exudativum, E. nodosum, and urticaria may be present.
Herpes. — Herpes is certainly rare in typhoid fever in comparison with
its great frequency in malarial fever and in pneumonia. It was noted in
20 of our 1,500 cases, usually on the lips.
The taches hleudtres — Peliomata — Maculce cerulce. — These are pale-blue
or steel-gray spots, subcuticular, fxom 4 to 10 mm. in diameter, of irregu-
lar outline and most abundant about the chest, abdomen, and thighs. They
sometimes give a very striking appearance to the skin. They are due to lice
(see Pediculosis).
STcin Gangrene. — In children noma may occur; as reported by McFarland
in the Philadelphia epidemic of 1898 there were many cases with multiple
areas of gangrene of the skin. The nose, ears, and genitals may be attacked.
Sweats. — At the height of the fever the skin is usually dry. Profuse
sweating is rare, but it is not very uncommon to see the abdomen or chest
moist with perspiration, particularly in the reaction which follows the bath.
Sweats in some instances constitute a striking feature of the disease. They
may occasionally be associated with chilly sensations or actual chills. Jac-
coud and others in France have especially described this sudoral form of
typhoid fever. There may be recurring paroxysms of chill, fever, and sweats
(even several in twenty-four hours), and the case may be mistaken for one
of intermittent fever. The fever toward the end of the second week and
during the third week may be intermittent. The characteristic rash is usu-
ally present, and, if absent, the negative condition of the blood is sufficient
to exclude malaria. The sweating may occur chiefly in the third and fourth
weeks.
(Edema of the skin occurs: 1, As the result of vascular obstruction, most
commonly of a vein, as in thrombosis of the femoral vein. 2. In connection
with nephritis, very rarely. 3. In association with the anaemia and cachexia.
A yellow color of the palms of the hands and of the soles of the feet is not
uncommon. The hair falls out after the attack, but complete baldness is rare.
I have once seen permanent baldness. The nutrition of the nails suffers, and
during and after convalescence transverse ridges may occur. A peculiar odor
is exhaled from the skin in some cases. Whether due to a cutaneous exhala-
tion or not, there certainly is a very distinctive smell connected with many
patients. Nathan Smith describes it as of a " semi-cadaverous, musty char-
acter."
LinecB atrophicce. — Lines of atrophy may appear on the skin of the abdo-
men and lateral aspects of the thighs, similar to those seen after pregnancy.
They have been attributed to neuritis, and Duckworth has reported a case
in which the skin adjacent to them was hyperaesthetic.
Bed-sores are not uncommon in protracted cases, with great emaciation.
As a rule, they result from pressure and are seen upon the sacrum, more
rarely the ilia, the shoulders, and the heels. These are less common, I think.
76 SPECIFIC INFECTIOUS DISEASES.
since the introduction of hydrotherapy. Scmpulous care and watchftiliies&
do much for their prevention, but it is to be remembered that in cases with
profound involvement of the nerve centres acute bed-sores of the back and
heels may occur with very slight pressure, and with astonishing rapidity.
Boils constitute a common and troublesome sequel of the disease. They
appear to be more frequent after hydrotherapy.
Circulatory System. — The hJood presents important changes. The fol-
lowing statements are based on studies which W. S. Thayer has made in
my wards (Studies I and III) : During the first two weeks there may be
little or no change in the blood. Profuse sweats or copious diarrhoea may,
as Hayem has shown, cause the corpuscles — as in the collapse stage of cholera.
— ^to rise above normal. In the third week a fall usually takes place in cor-
puscles and hemoglobin, and the number may sink rapidly even to 1,300,000
per c. mm., gradually rising to normal during convalescence. When the-
patient first gets up, there may be a slight fall in the number of corpuscles.
The average maximum loss is about 1,000,000 to the c. mm.
The amount of hagmoglobin is always reduced, and usually in a greater
relative proportion than the number of red corpuscles, and during recov-
ery the normal color standard is reached at a later period. Leucopenia —
hypoleucocytosis — is present throughout the course. Cold baths increase
temporarily the number of leucocytes in the peripheral circulation. The
absence of leucoc}i:osis may be at times of real diagnostic value in distinguish-
ing typhoid fever from various septic fevers and acute inflammatory processes.
The polymorphonuclear leucoc}i;es are normal in number, while the lympho-
cytes are relatively increased. When an acute inflammatory process occurs in
typhoid fever the leucoc}i;es show an increase in the pol}Tiuclear forms, and
this may be of great diagnostic moment.
The accompanying blood-chart shows these changes well. (Chart III.)
The post-t}^hoid anaemia may reach an extreme grade. In one of my
cases the blood-corpuscles sank to 1,300,000 per e. mm. and the hsemoglobin
to about 20 per cent. These severe grades of anaemia are not common in
my experience. In the Munich statistics there were 54 cases with general
and extreme anaemia.
Of changes in the blood plasma very little is known.
The pulse in typhoid fever presents no special characters. It is increased
in rapidity, but not always in proportion to the height of the fever, and this
may be a very special feature in the early stages. As a rule, in the first week
it is above 100, full in volume and often dicrotic. There is no acute disease
with which, in the early stage, a dicrotic pulse is so frequently associated.
Even with high fever the pulse may not be greatly accelerated. As the dis-
ease progresses the pulse becomes more rapid, feebler, and small. In 6 per
cent of our cases the pulse rate rose above 140 (Thayer). In the extreme
prostration of severe cases it may reach 150 or more, and is a mere undula-
tion— ^the so-called running pulse. The lowered arterial pressure is mani-
fest in the dusky lividity of the skin and coldness of the hands and feet.
During convalescence the pulse gradually returns to normal, and occa-
sionally becomes very slow. Aiter no other acute fever do we so frequently
meet with bradycardia. I have counted the pulse as low as 30, and in-
stances are on record of still fewer beats to the minute. Tachycardia, while
TYPHOID FEVER.
11
less common, may be a very troublesome and persistent feature of con-
valescence.
Blood Pressure. — This is usually from 115-125 m. m. Hg. (Riva-Eocci
instrument) in systole. The diastolic pressure has the normal relationship
to the systolic, and averages 85-100 m. m. Hg. There is a gradual fall during
the course to about 100-110 m. m. Hg. at the beginning of apyrexia. In two
5,000,000
DEC , 1890
JANUARY, .189.1
FEBRUARY.
MARCH 1
lUU^
19
22
25
28
31
3
s
9
12
15
18
21
24
27
30
2
5
8
11
14
17
20
23
26
1
4
7
10
13
16
19
90^
80%
4,000,000
1
/
70^
/
/
m%
3,000,000
I
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/
50%
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MEAN NORM.
NUMBER OF
WHITE
CORPUSCLES
BLACK, RED CORPUSCLESi
REDjHAEMOaLOBiri.
Chart III.
BLUE, COLORLESS CORPUSCLES.
or three weeks later the pressure has usually returned to normal. Haemor-
rhage usually produces a marked fall both in the systolic and diastolic pres-
sure. In some cases of perforation there is a sharp rise in systolic pressure.
Tubs and ice sponges usually cause a rise of 10-20 m. m. Hg.
The heart-sounds may be normal throughout the course. In severe cases,
the first sound becomes feeble and there is often to be heard, at the apex and
-along the left sternal margin, a soft systolic murmur, which was present in
78 SPECIFIC INFECTIOUS DISEASES.
22 per cent of our cases. Absence of the first sound is rare. Gallop rhythm
is not uncommon. In the extreme feebleness of the graver forms, the first
and second sound become very similar^ and the long pause is much shortened
(embryocardia).
Of cardiac complications, pericarditis is rare and has been met with
chiefly in children and in association with pneumonia. It was present in
three of my series and occurred in only 14 of the 2,000 Munich post mortems.
Endocarditis was found post mortem in three cases, and the ph^^sical signs
suggested its presence in three other cases in the series. Myocarditis is more
common, and is indicated by a progressive weakening of the heart-sound and
enfeeblement of the action of the organ.
Complications in the Arteries. — Arteritis with thrombus formation oc-
curred in four cases in the series, one in the branches of the middle cerebral,
two in the femoral, and one in the brachial. In one case gangrene of the
leg followed. I saw a similar case with Eoddick, in Montreal, in which
obliteration of the left femoral artery occurred on the sixteenth day, and of
the vessel on the right side on the twentieth day, with gangrene of both feet.
Pain, tenderness, and swelling occur over the artery, with diminution of dis-
appearance of the pulsations and coldness and blueness of the extremity.
In two of the cases these s}Tnptoms gradually disappeared, and the pulsation
returned not only in the peripheral, but in the affected vessels (Thayer).
Keen refers to 46 cases of arterial gangrene, of which 8 were bilateral, 19 on
the right side, and 19 on the left.
Tlirombi in the Veins. — In our series there were 41 instances, distributed
in the following veins : femoral 23, popliteal 5, iliac 5, veins of the calf 5,
internal saphenous 3, pulmonary artery alone 1, pulmonary artery and com-
mon iliac 1, axillary vein 1 (Thayer). I saw one case in the right circum-
flex iliac vein. Femoral thrombosis is the most common, and almost inva-
riably in the left vessel, due, as Liebermeister suggests, to the fact that the
left iliac vein is crossed by the right iliac artery, and the blood flow is not
so free. The symptoms of this complication are very definite — ^the fever may
increase or recur. Chills occurred in 11 of all the cases. Pain and swelling
at the site are constanth' present, and the thrombotic mass can be felt, not
always at first, nor is it well to feel for it. Swelling of the leg follows as a
rule, but it is rarely so extreme, and never, I think, so painful as the puer-
peral phlegmasia alba dolens. In the iliac thrombosis the pain may be severe
and lead to the suspicion of perforation, as in one of our cases. Leucoc}^-
tosis is usually present, in 12 cases it rose above 10,000. Five of the 39 cases
died, 2 only as a result of the thrombus; in the case of axillary thrombosis
from pulmonary embolism, in one embolism of the inferior cava and right
auricle from the dislocation of a piece of thrombus from the left iliac vein.
Thayer examined 16 of the patients at varying periods after convalescence,
and found in every case more or less disability from the varices and persist-
ent swelling. In some cases, however, the recovery is complete.
Digestive System. — Loss of appetite is early, and, as a rule, the relish
for food is not regained until convalescence. Thirst is constant, and should
be fully and freely gratified. Even when the mind becomes benumbed and
the patient no longer asks for water, it should be freely given. The tongue
presents the changes inevitable in a prolonged fever. Early in the disease
TYPHOID FEVER. 79
it is moist, swollen, and coated with a thin white fur, which, as the fever
progresses, becomes denser. It may remain moist throughout. It is small
in size and tends to be red at the edges and tip. In severe cases, particu-
larly those with delirium, the tongue becomes very dry, partly owing to the
fact that such patients breathe with the mouth open. It may be covered
with a brown or brownish-black fur, or with crusts between which are cracks
and fissures. Acute glossitis occurred in one case at the onset of the relapse'.
In these cases the teeth and lips may be covered with a dark brownish matter
called sordes — a mixture of food, epithelial debris, and micro-organisms. By
keeping the mouth and tongue clean from the outset the fissures, which are
extremely painful, may be prevented. During convalescence the tongue grad-
ually becomes clean, and the fur is thrown off, almost imperceptibly or occa-
sionally in fiakes.
The secretion of saliva is often diminished; salivation is rare.
Parotitis was present in 45 of the 2,000 Munich cases. It occurred in
14 cases in my series; of these, 5 died. It is most frequent in the third
week in very severe cases. Extensive sloughing may follow in the tissues
of the neck. Usually unilateral, and in a majority of cases going on to sup-
puration, it is regarded as a very fatal complication, but recovery has fol-
lowed in eight of my cases. It undoubtedly may arise from extension of
infiammation along Steno's duct. This is probably not so serious a form
as when it arises from metastatic inflammation. In four cases the submax-
illary glands were involved alone, in one a cellulitis of the neck extended
from the gland and proved fatal. Parotitis may occur after the fever has
subsided. A remarkable localized sweating in the parotid region is an occa-
sional sequel of the abscess.
The pharynx may be the seat of slight catarrh. Sometimes the fauces
are deeply congested. Membranous pharyngitis, a serious and fatal com-
plication, may come on in the third week. Difficulty in swallowing may
result from ulcers of the oesophagus, and in one of our cases stricture fol-
lowed.* Thyroiditis may occur with abscess formation.
The gastric symptoms are extremely variable. Nausea and vomiting are
not common. There are instances, however, in which vomiting, resisting all
measures, is a marked feature from the outset, and may directly cause death
from exhaustion. Vomiting does not often occur in the second and third
weeks, unless associated with some serious complication. Ulcers have been
found in the stomach. Hsematemesis occurred in 4 of our cases.
Intestinal Symptoms. — Diarrhoea is a very variable symptom, occurring
in from 20 to 30 per cent of the cases. Of 1,500 cases, 516 had diarrhoea before
entering, 260 during their stay in hospital. The small percentage may be
due to the fact that we use no purges or intestinal antiseptics. Its absence
must not be taken as an indication that the intestinal lesions are of slight
extent. I have seen, on several occasions, the most extensive infiltration and
ulceration of the Peyer's glands of the small intestine, with the colon filled
with solid faeces. The diarrhoea is caused less by the ulcers than by the asso-
ciated catarrh, and, as in tuberculosis, it is probable that when this is in the
large intestine the discharges are more frequent. It is most common toward
* Mitchell, CEsophageal Complications in Typhoid Fever (Studies II).
80 SPECIFIC INFECTIOUS DISEASES.
the end of the first and throughout the second week, but it ma)^ not occur
until the third or even the fourth week. The number of discharges ranges
from 3 to 8 or 10 in the twenty-four hours. They are usually abundant,
thin, grayish-yellow, granular, of the consistency and appearance of pea-soup,
and resemble very much, as Addison remarked, the normal contents of the
small bowel. The reaction is alkaline and the odor ofEensive. On standing,
the discharges separate into a thin serous layer, containing albumin and salts,
and a lower stratum, consisting of epithelial dehris, remnants of food, and
numerous crystals of triple phosphates. Blood may be in small amount, and
only recognized b}" the microscope. Sloughs of the Peyer's glands occur
either as grayish-j^ellow fragments or occasionally as ovoid masses, an inch or
more in length, in which portions of the bowel tissue may be found. The
bacilli are not found in the stools until the end of the first or the middle of
the second week. Constipation was present in 51 per cent of the cases.
Hwmorrliage from the bowels is a serious complication, occurring in from
3 to 5 per cent of all cases. It had occurred in 99 of the 2,000 fatal Munich
cases. In 1,500 cases treated in my wards, haemorrhage occurred in 118, and
in 12 death occurred directly from the haemorrhage. It was present in 3.77
per cent of Murchison's 1,564 cases. There may be only a slight trace of
blood in the stools, but too often it is a profuse, free hgemorrhage, which
rapidly proves fatal. It occurs most commonly between the end of the second
and the beginning of the fourth week, the time of the separation of the
sloughs. Occasionally it results simply from the intense hypersemia. It usu-
ally comes on without warning. A sensation of sinking or collapse is experi-
enced by the patient, the temperature falls, and may, as in the annexed chart,
drop 6° or 7° in a few hours. Fatal collapse may supervene before the blood
appears in the stool. Haemorrhage usually occurs in cases of considerable
severity. Graves and Trousseau held that it was not a very dangerous symp-
tom, but statistics show that death follows in from 30 to 50 per cent of
the cases.
It must not be forgotten that melsna may also be part of a general heem-
orrhagic tendency (to be referred to later), in which case it is associated with
petechias and h^ematuria. There may be a special family predisposition to
intestinal haemorrhages in typhoid fever.
Meteorism, a frequent symptom, is not serious if of moderate grade, but
when excessive is usually of ill omen. Owing to defective tone in the walls,
in severe cases to their infiltration with serum, gas accumulates in the small
and large bowels, particularly in the latter. Pushing up the diaphragm, it
interferes very much with the action of the heart and lungs, and may also
favor perforation. Gurgling in the right iliac fossa exists in a large propor-
tion of all the cases, and indicates simply the presence of gas and fluid faeces
in the colon and caecum.
Atdominal pain and tenderness were present in three-fifths of a series
of 500 cases studied with special reference to the point by T. McCrae. In
some it was only present at the onset. Pain occurred during the course in
about one-third of the cases. This is due in some instances to conditions'
apart from the bowel lesions, such as pleurisy, distention of the bladder, and
phlebitis. It may be associated with diarrhoea, severe constipation, a painful
spleen, or acute abdominal complications. Pain occurs with some cases of
TYPHOID FEVER.
81
haemorrhage, but is most constantly present with perforation. In a large
group no cause could be found for the pain, and if other symptoms be asso-
ciated the condition may lead to error in diagnosis. Operation for appendi-
citis has been performed in the early stage of typhoid fever, owino- to the
combination of pain in the right iliac fossa, fever and constipation. This
has happened twice at the Johns Hopkins Hospital,
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Peepoeation. — From one-fourth to one-third of the deaths are due to
perforation, and as there were 35,379 deaths from typhoid fever in the United
States in the year 1900, this gives between 9,000 and 13,000 deaths from
this cause. Watchful care on the part of the physician should result in a
saving of at least one-third of the cases. While it may occur as early as the
82 SPECIFIC INFECTIOUS DISEASES.
first week, in the great majority it is at the height of the disease in the third
week, and much more frequently in the severe cases, particularly those asso-
ciated with tympanites and haemorrhage. It may occur, however, in very-
mild cases and with great suddenness, when the patient is apparently pro-
gressing favorably.
Symptoms of Perforation. — By far the most important single indication is
a sudden, sharp pain of increasing severity, often paroxysmal in character. It
is rarely absent, except in the small group of cases with profound toxaemia.
The situation is most frequent in the hypogastric region and to the right of
the middle line. Tenderness on pressure is present in the great majority of
cases, usually in the hypogastric and right iliac regions, sometimes diffuse;
it may only be brought out on deep pressure. As LeConte points out, when
the perforation happens to be in contact with the parietal peritonaeum the
local features on palpation are much more marked than when the perforated
Tilcer is next to a coil or to the mesentery. There may be early irritability
of the bladder, with frequent micturition, and pain extending toward the
penis. A third important sign is muscle rigidity, increased tension, and
spasm on any attempt to palpate. "With the onset of these features the
patient may have signs of shock — a fall in temperature, an increase in the
rapidity of the pulse and respirations, and slight sweating. Following these
features in a few hours there is usually a reaction, and then the features of
general peritonitis become manifest to a more or less marked degree. Among
the general features, the fades of the patient shows changes; there is in-
creased pallor, a pinched expression of the face, and as the symptoms pro-
gress and toward the end a marked Hippocratic f acies, a dusky sufEusion,
and the forehead bathed in a clammy perspiration. The temperature, which
often drops at the onset of a perforation, rises with the increase of the peri-
tonitis. The pulse quickens, is running and thready, the heart's action
becomes progressively more feeble, and there is an increase in the frequency
of the respiration. Vomiting is a variable feature; it is present in a major-
ity of the cases. Hiccough is common and may occur earl}-, but more fre-
quently late.
The local abdominal features are often more important than the gen-
eral, as it is surprising to notice how excellent the condition of a patient
may be with perforative peritonitis. Limitation of the respiratory move-
ments is usually present, perhaps confined to the hypogastric area. In-
creasing distention is the rule, but perforation and peritonitis may occur,
it is to be remembered, with an abdomen flat or even scaphoid. Increasing
pain on pressure, increasing muscle spasm and tension of the wall are im-
portant signs. Percussion ma)^ reveal a flat note in the flanks, due to exu-
date. Auscultation may show absence of peristalsis, and auscultatory percus-
sion may possibly show the presence of air free in the peritonaeum. A friction
may be present within a few hours of the onset of the perforation. Obliter-
ation of the liver flatness in the nipple line may be caused by excessive
tympany. Eapid obliteration of liver flatness in a flat, or a not much dis-
tended abdomen, is a valuable sign. Examination of the rectum may show
fullness in the pelvis, or tenderness.
In a majority of all cases th^re is a rise in the leucocytes, and when pres-
ent may be a valuable help, but it is not constant.
TYPHOID FEVER. 83
General peritonitis, without perforation of the howel, may occur by exten-
sion from an ulcer, or by rupture of a softened mesenteric gland, or, as in
one recent case in my series, from inflammation of the Fallopian tubes. It
was present in 2.2 per cent of the Munich autopsies.
Perforation is almost invariably fatal. In a few cases healing takes place
spontaneously, as is beautifully shown in one of the Pennsylvania Hospital
specimens, or the orifice may be closed by a tag of omentum, as in a remark-
able case reported by J. Milton Miller.
There is a group of cases in which haemorrhage complicates the perfora-
tion and adds to the difficulty in diagnosis. In 7 of our 43 cases haemorrhage
accompanied the perforation ; in 3 others the haemorrhage had occurred some
days before.
The diagnosis of perforation, easy enough at times, is not without serious
difficulties. The conditions for which it has been mistaken in my wards have
been : appendicitis, occurring during the course of the typhoid fever, phlebitis
of the iliac vein with great pain, haemorrhage, and in one case a local perito-
nitis without perforation, for which no cause was found. Eecovery followed
the exploratory operation, which was made in all but one (haemorrhage case)
of these cases.
The SPLEEN is usually enlarged, and the edge was felt below the costal
margin in 71.6 per cent of my cases. Percussion is uncertain, as, owing to
distention of the stomach and colon, even the normal area of dulness may
not be obtainable. I have seen a very large spleen post mortem, when during
life the increase in size was not observable.
LiVEE. — Symptoms on the part of this organ are rare.
(a) Jaundice was present in only 8 cases of my series. Catarrh of
the ducts, toxEemia, abscess, and occasionally gall-stones are the usual
causes.
(h) Abscess. — Solitary abscess is exceedingly rare and occurred in but 3
cases in my series. It may follow the intestinal lesion or more commonly
one of the complications, as parotitis or necrosis of bone. Suppurative pyle-
phlebitis, which is more frequent than abscess, may follow perforation of
the appendix. Suppurative cholangitis has been described.
(c) Cholecystitis occurred in 19 cases of the series. Camac * has col-
lected 115 cases, in 21 of which perforation occurred. Pain in the region
of the gall-bladder is the most constant symptom. Tenderness, muscle spasm
with rigidity, and a gall-bladder tumor are present in a majority of the cases.
Jaundice is inconstant. With perforation there may be a marked drop in
the fever and the onset of signs of peritonitis. In simple cholecystitis the
urgency of the symptoms may abate, and recovery may follow. Suppura-
tion may occur with infection of the bile passages. Months or years after
(eighteen years in Hunner's case) the bacilli may cause cholecystitis or gall-
stones. Typhoid bacilli have been found by Gushing as a cause of cholecys-
titis in a patient who had never had typhoid fever.
(d) Gall-Stones. — Bernheim called attention to the frequency of chole-
lithiasis after typhoid fever. It is probably associated with the presence
of typhoid bacilli in the gall-bladder (see under Gall-Stones).
* Studies in Typhoid Fever, Series III, Johns Hopkins Hospital Reports, vol. viii.
84 SPECIFIC INFECTIOUS DISEASES.
Eespiratoey System. — Epistaxis, an early symptom, precedes typhoid
fever more commonly than any other febrile afEection. It is occasionally
profuse and serious.
Laryngitis is not very common. The ulcers and the perichondritis have
already been described. Oedema, apart from ulceration, is rare. In the
United States the laryngeal complications of typhoid fever seem much less
frequent than on the Continent. I have twice seen severe perichondritis;
both of the cases recovered, one after the expectoration of large portions of the
thyroid cartilage.
Keen and Liining have collected 331 cases of serious -surgical complica-
tions of the larynx. General emphysema may follow the perforation of an
ulcer. Stenosis is a very serious sequence.
From some recent studies it would appear that paralysis of the laryn-
geal muscles is much more common than we have supposed. Przedborski
(Volkmann's Sammlung, ISTo. 183) has systematically examined the larynx
in 100 consecutive cases and found 85 with paralysis. The condition is
nearly always due to neuritis, sometimes in connection with affections of
other nerves.
Bronchitis is one of the most frequent initial symptoms. It is indicated
by the presence of sibilant rales. The smaller tubes may be involved, pro-
ducing urgent cough and even slight cyanosis. Collapse and lobular pneu-
monia may also occur.
Lobar pneumonia is met with under two conditions :
1. At the outset the pneumo-typlius of the Germans. This occurred in
three of our cases. After an indisposition of a day or so, the patient is seized
with a chill, has high fever, pain in the side, and within forty-eight hours there
are signs of consolidation and the evidences of an ordinary lobar pneumonia.
The intestinal symptoms may not occur until toward the end of the first
week or later; the pulmonary symptoms persist, crisis does not occur; the
aspect of the patient changes, and by the end of the second week the clinical
picture is that of typhoid fever. Spots may then be present and doubts as
to the nature of the case are solved. In other instances, in the absence of
a characteristic eruption, the case remains doubtful, and it is impossible to
say whether the disease has been pneumonia, in which the so-called typhoid
symptoms have developed, or whether it was typhoid fever with early implica-
tion of the lungs. This condition may depend upon an early localization of
the typhoid bacillus in the lung.
3. Lobar pneumonia forms a serious and by no means infrequent com-
plication of the second or third week — in 19 of our cases. It was present in
over 8 per cent of the Munich cases. The symptoms are usually not marked.
There may be no rusty sputa, and, unless sought for, the condition is fre-
quently overlooked. The etiological agent in these cases is still in dispute.
T_yphoid bacilli have been isolated from the sputum by Jehle, Eau, and others.
They have also been isolated from the consolidated lungs at autopsy, but in
such cases the pneumococci may have been originally present, and the typhoid
bacilli secondary invaders. In all cases of pneumonia during typhoid fever
occurring in the Johns Hopkins Hospital and coming to autopsy, the pneu-
mococci could be demonstrated in the consolidated lung. Infarction, abscess,
and gangrene are occasionally pulmonary complications.
TYPHOID FEVER. 85
Hypostatic congestion of the lungs and oedema, due to enfeebled circu-
lation in the later periods of the disease, are very common. The physical
signs are defective resonance at the bases, feeble breath-sounds, and, on deep
inspiration, moist rales.
Hcemo'ptysis may occur. Creagh reports a case in which it caused death.
Pleurisy was present in about 8 per cent of the Munich autopsies. It
may occur at the outset — pleuro-typhoid — or slowly during convalescence,
in which case it is almost always purulent and due to the typhoid bacilli.
Pneumothorax is rare. Hale White has reported two cases, in both of
which pleurisy existed. After death, no lesions of the lungs or bronchi were
discovered. The condition may be due to straining, or to the rupture of a
small pygemic abscess. It may occur also during convalescence.
Nervous System. — Cereiro-spinal Form. — As already noted, the disease
may set in with intense and persisting headache, or an aggravated form of
neuralgia. There are cases in which the effect of the poison is manifested
on the nervous system early and with the greatest intensity. There are head-
ache, photophobia, retraction of the neck, marked twitchings of the muscles,
rigidity, and even convulsions. In such cases the diagnosis of meningitis is
invariably made. The cases showing marked meningeal features during the
course of the disease may be divided into three groups. First, those with symp-
toms suggestive of meningitis, but without localizing features and without
at post mortem the anatomical lesions of meningitis. In every series of
cases numerous such examples occur. Secondly, the cases of so-called serous
meningitis. There is a localization of typhoid bacilli in the cerebro-spinal
fluid and a mild inflammatory reaction, but Avlthout suppurative meningitis.
Cole has collected thirteen such cases, five of them occurring in our series.
Probably more frequent lumbar punctures will show that this occurs not
infrequently. Thirdly, true typhoid suppurative meningitis due to B. typho-
sus. Only one such case occurred in our series, and Cole has collected thir-
teen from the literature. Meningitis in typhoid fever is occasionally due to
other organisms, as tubercle bacilli, and the micrococcus intracellularis.
Marked convulsive movements, local or general, with coma and delirium, are
seen also in thrombosis of the cerebral veins and sinuses.
Delirium, usually present in very severe cases, is certainly less frequent
under a rigid plan of hydrotherapy. It may exist from the outset, but usu-
ally does not occur until the second and sometimes not until the third week.
It may be slight and only nocturnal. It is, as a rule, a quiet delirium, thovigh
there are cases in which the patient is very noisy and constantly tries to get
out of bed, and, unless carefully watched, may escape. The patient does
not often become maniacal. In heavy drinkers the delirium may have the
character of delirium tremens. Even in cases which have no positive
delirium, the mental processes are usually dulled and the aspect is listless
and apathetic. In severe cases the patient passes into a condition of uncon-
sciousness. The eyes may be open, but he is oblivious to all surrounding cir-
cumstances and neither knows nor can indicate his wants. The urine and
faeces are passed involuntarily. In this pseudo-wakeful state, or coma vigil,
as it is called, the eyes are open and the patient is constantly muttering.
The lips and tongue are tremulous; there are twitchings of the fingers and
wrists — subsultus tendinum and carphologia. He picks at the bedclothes or
86 SPECIFIC INFECTIOUS DISEASES.
grasps at invisible objects. These are among the most serious symptoms of
the disease and always indicate danger.
Convulsions in typhoid fever are rare. There were 8 instances in sixteen
years among between fifteen and sixteen hundred cases. They occur: first,
at the onset of the disease, particularly in children; secondly, as a manifes-
tation of the toxaemia; and thirdly, as a result of severe cerebral complica-
tions— thrombosis, meningitis, or acute encephalitis. Occasionally in con-
valescence convulsions may occur from unknown causes. Of the 8 cases
3 died.
Neuritis, which is not uncommon — 11 cases in the series — may be local, or
a wide-spread affection of the nerves of the legs or of both arms and legs.
Local Neuritis. — This may occur during the height of the fever or after
convalescence is established. It may set in with agonizing pain, and with
sensitiveness of the affected nerve trunks. The local neuritis may affect
the nerves of an arm or of a leg, and involve chiefly the extensors, so that
there is wrist-drop or foot-drop. The arm or leg may be much swollen
and the skin over it er}d:hematous. Painful muscles are not uncommon, par-
ticularly in the calves. I have reported a series of cases (Studies III).
Painful cramps may also occur. In some of the cases of painful legs the
condition is a myositis ; in others the swelling and pain may be due to throm-
bosis in the deeper veins.
A curious condition, probably a local neuritis, is that which was first
described by Handford as tender toes, and which appears to be much more
common after the cold-bath treatment. The tips and pads of the toes, rarely
the pads at their bases, become exquisitely sensitive, so that the patient can
not bear the weight of the bedclothes. There is no discoloration and no
swelling, and it disappears usually within a week or ten days.
Multiple neuritis in typhoid fever comes on usually during convalescence.
The legs may be affected, or the four extremities. The cases are often diffi-
cult to differentiate from those with subacute poliomyelitis. Recovery is
the rule.
Poliomyelitis may occur with the s3^mptoms of acute ascending paral-
ysis and prove fatal in a few days. More frequently it is less acute, and
causes either a paraplegia or a limited atrophic paralysis of one arm or leg.
Hemiplegia is a rare complication. Francis Hawkins has collected 17
cases from the literature; aphasia was present in 12. The lesion is usually
thrombosis of the arteries, less often a meningo-encephalitis. The aphasia
usually disappears.
True tetany occurs sometimes, and has been reported in connection with
certain epidemics. It may set in during the full height of the disease.
Typhoid Psychoses. — There are three groups of cases : first, an initial
delirium, which may be serious, and cause the patient to wander away from
his home, or he may even become maniacal; secondly, the psychosis asso-
ciated directly vrith the p}Texia and the toxaemia; in a few cases this outlasts
the disappearance of the fever for months or even years; and, lastly, the
asthenic psychosis of convalescence, more common after typhoid than after
any other fever. The prognosis is usually good. Edsal has recently studied
the condition in children, finding 69 cases in the literature, of which 43
recovered.
TYPHOID FEVER. 87
There is a distressing post-typhoid neurasthenia, in which for months or
even for years the patient is unable to get into harmony with his sur-
roundings.
Special Senses. — Eye. — Conjunctivitis, simple or phlyctenular, some-
times with keratitis and iritis, may develop. Panophthalmitis has been
reported in one case in association with haemorrhage (Finlay). Loss of accom-
modation may occur, usually in the asthenia of convalescence. Oculo-motor
paralysis has been seen, due probably to neuritis. Eetinal haemorrhages may
occur alone or in association with other haemorrhagic features. Double optic
neuritis has been described in the course of the fever. It may be independent
of meningitis. Atrophy may follow, but these complications are excessively
rare. Cataract may follow inflammation of the uveal tract. Other rare com-
plications are thrombosis of the orbital veins and orbital haemorrhage. (See
De Schweinitz in Keen's monograph for full consideration of the subject.)
Ear. — Otitis media is not infrequent, 2.5 per cent in Hengst's collected
cases. We have never found the typhoid bacillus in the discharge. Seri-
ous results are rare; only one case of mastoid disease occurred in our series.
The otitis may set in with a chill and an aggravation of the fever.
Eenal System. — Retention of urine is an early symptom and may be the
cause of abdominal pain. It may recur throughout the attack. Suppres-
sion of urine is rare. The urine is usually diminished at first, has the ordi-
nary febrile characters, and the pigments are increased. Later in the disease
it is more abundant and lighter in color.
Polyuria is not very uncommon. The amount of water depends very
much on the fluid taken. In certain cases enormous quantities are passed,
up to seven and eight quarts. While most common during convalescence, the
increase may be sudden in the second week at the height of the fever, as in
a case reported by Fussell. Patients treated by what is known as the wash-
ing-out method, in which large quantities of water are taken, may pass enor-
mous amounts, 18 or 19 litres. One of my patients passed as much as 33
litres in one day !
The Diazo-reaction of EhrUch. — Two solutions are employed, kept in
separate bottles : one containing a saturated solution of sulphanilic acid in
a solution of hydrochloric acid (50 cc. to 1,000 cc.) ; the other a half per
cent solution of sodium nitrite. To make the test, a few cubic centimetres
of urine are placed in a small test-tube with an equal quantity of a mixture
of the solution of the sulphanilic acid (-10 cc.) and the sodium nitrite (1 cc),
the whole being thoroughly shaken. One cubic centimetre of ammonia is
then allowed to flow carefully down the side of the tube, forming a colorless
zone above the yellow urine, and at the junction of the two a deep brownish-
red ring will be seen if the reaction is present. With normal urine a lighter
brownish ring is produced, without a shade of red. The color of the foam of
the mixed urine and reagent, and the tint they produce when largely diluted
with water, are characteristic, being in both cases of a delicate rose-red if the
diazo-reaction be present; but if not, brownish-yellow. It was found in 894
of 1,467 cases. It may be present previous to the occurrence of the rash, and
as late as the twenty-second day. The value of the test is lessened by its
occurrence in cases of miliary tuberculosis, in malarial fever, and occasion-
ally in the acute diseases associated with high fever. The urotoxic coefficient
88 SPECIFIC INFECTIOUS DISEASES.
in typhoid fever is high and is said to be increased by the tubs. In cases
passing large quantities of urine the diazo-reaction is very feeble or even
absent.
BaciUuria occurs in about one-third of the cases, caused by the typhoid
bacilli. The urine may be turbid from their presence and in the test-tube
give a peculiar shimmer. There may be millions of bacilli to the cubic milli-
metre without pyuria or any symptoms of renal or bladder trouble. The
bacilli may be present in the urine for years after the attack (see Gwyn,
Studies III). Of 51 cases during the session of 1900-1901 in my clinic.
Cole found typhoid bacilli in the urine in 16.
The renal complications in typhoid fever may be thus grouped :
(a) Febrile albuminuria is common and of no special significance. It
was present in 999 of 1,500 cases, 66 per cent. Tube casts were present in
568 cases, 37.8 per cent. Hamoglohinuria occurred in one case.
(&) Acute nephritis at the onset or during the height of the disease —
the nephro-typlius of the Germans, the fievre typho'ide a forme renale of the
French — may set in, with all the symptoms of acute Bright's disease, mask-
ing in many instances the true nature of the malady. After an indisposi-
tion of a few days there may be fever, pain in the back, and the passage of
a small amount of bloody urine.
(c) jSTephritis during convalescence is rare, and is usually associated with
anaemia and oedema. Chronic nephritis is a most exceptional sequel of the
disease.
{d) The lymphomatous nephritis, described by E. Wagner, and already
referred to in the section on morbid anatomy, produces, as a rule, no
symptoms.
(e) Pyuria, a not uncommon complication, may be associated with the
typhoid or the colon bacillus, less often with staphylococci. It disappears
during convalescence. It is usually due to a simple catarrh of the bladder,
rarely to an intense cystitis.
(/) Post-typhoid Pyelitis. — One or both kidneys may be involved, either
at the height of the disease or during convalescence. There may be blood
and pus at first, later pus alone, varying in amount. A severe pyelonephritis
may follow. Perinephric abscess is a rare sequel.
Generative System. — Orchitis is occasionally met with. Kinnicutt has
collected 53 cases in the literature. It is usually associated with a catarrhal
urethritis. Induration or atrophy may occur, and more rarely suppuration.
It was present in 4 cases in my series. In 1 case double hydrocele developed
suddenly on the nineteenth day (Dunlap).
Acute mastitis, which may go on to suppuration, is a rare complication.
It was present in 3 cases of my series, during the fever and in one late in
convalescence.
Osseous System. — Among the most common and troublesome of the
sequelae of the disease are the hone lesions. In a few cases the bone lesions
occur at the height of the disease or even earlier. A boy was admitted in the
second week of an attack of typhoid fever with acute periostitis of the frontal
bone and of one rib. Of 237 cases collected by Keen there were periostitis in
110, necrosis in 85, and caries in 13. They are, I am sure, much more frequent
than the figures indicate. Six cases came under my notice in the course of a
TYPHOID FEVER. 89
year, and formed the basis of Parsons' paper (Studies II). The legs are chiefly
involved. In Keen's series the tibia was affected in 91 cases, the ribs in 40.
The typhoid bone lesion is apt to form what the old writers called a cold
abscess. Only a few of the cases are acute. Chronicity, indolence, and a
remarkable tendency to recurrence are perhaps the three most striking
features of the typhoid bone lesions. A bony node may be left by the typhoid
periostitis.
Arthritis was present in 5 cases of my series. Eheumatic and septic forms
are described, as well as a typhoid arthritis proper. The complication is exceed-
ingly rare, and yet Keen has collected from the literature 84 cases. One of the
most important points relating to it is the frequency with which spontaneous
dislocations occur, particularly of the hip.
Typhoid Spine (Gibney). — During the disease in protracted cases, more
often during convalescence, the patient complains of pain in the lumbar and
sacral regions, perhaps after a slight jar or shock. Stiffness of the back, pain
on movement, and tenderness on pressure are the chief features, but there are
in addition marked nervous, sometimes hysterical manifestations. The diag-
nosis of spondylitis. Pott's disease, or perinephritic abscess, etc., may be made.
The examination is negative. The patient is afebrile, as a rule. The outlook
is good. In rare instances there may be perispondylitis, but usually the condi-
tion is a neurosis (Studies I).
The muscles may be the seat of the degeneration already referred to, but it
rarely causes any symptoms. Hsemorrhage occasionally occurs into the muscles,
and late in protracted eases abscesses may follow. Eupture of a muscle, usually
the rectus abdominis, may occur, possibly associated with acute hasmorrhagic
myositis.
Post-typhoid Septicaemia and Pyaemia. — In very protracted cases there may
recur after defervescence a slight fever (100°-101°), with sweats, which is pos-
sibly septic. In other cases for two or three weeks there are recurring chills,
often of great severity. They are usually of no moment in the absence of signs
of complication. (See Studies II and III.)
Typhoid pyaemia is not very uncommon, (a) Extensive furunculosis may
be associated with irregular fever and leucocytosis. (&) Following the fever
there may be multiple subcutaneous " cold " abscesses, often with a dark, thin
bloody pus. A score or more of these may appear in different parts. Pratt
has isolated the bacillus in pure culture from the subcutaneous abscesses, (c) A
crural thrombus may suppurate and cause a wide-spread pyaemia, (d) In rare
instances suppuration of the mesenteric glands, of a splenic infarct, a slough-
ing parotid bubo, a perinephric or perirectal abscess, acute necrosis of the bones,
or a multiple suppurative arthritis may cause pygemia. In other cases follow-
ing bed-sores or a furunculosis there occurs a general infection with pyogenic
organisms, with fatal result. In three such cases in our series staphylococci
were cultivated from the blood. In one case with many chills late in the dis-
ease, and the general condition excellent, typhoid bacilli were cultivated from
the blood.
Association of other Diseases. — Erysipelas is a rare complication, most com-
monly met with during convalescence. In 1,420 cases at Basel it occurred 10
times. Griesinger states that it is met with in 2 per cent. Measles or scarlet
fever may develop during the fever or in convalescence. Chicken-pox and noma
90 SPECIFIC INFECTIOUS DISEASES.
have been reported in children. Pseudo-membranous inflammations may occur
in the pharynx, larynx, or genitals.
Malarial and typhoid fevers may he associated, but a majority of the cases
of so-called typho-malarial fever are either remittent malarial fever or true
typhoid. It is interesting to note that among the 829 cases of typhoid fever
Plasmodia were found in the blood during the course of the disease in only 1
case. (See Lyon, Studies III.) Many of our typhoid-fever cases came from
malarious regions.
The s3'mptoms of influenza may precede the t3^phoid fever, or the two dis-
eases may run concurrently. There are cases of chronic influenza which simu-
late typhoid fever very closely.
Typhoid Fever and Tiiberculosis. — (a) The diseases may coexist. A per-
son with chronic tuberculosis may contract the fever. Of 80 autopsies in
typhoid fever, 4 presented marked tuberculous lesions. Miliary tuberculosis
and tj'phoid fever may occur together, (fe) Cases of typhoid fever with pulmo-
nary and pleuritic symptoms may suggest tuberculosis at the onset, (c) There
are five types of tuberculous infection which may simulate typhoid fever:
the acute miliary form (page 298) ; tuberculous meningitis (page 301) ; tuber-
culous peritonitis (page 310) ; the acute toxaemia of certain local lesions (page
306) ; and forms of ordinary pulmonary tuberculosis. And, lastly, pulmonary
tuberculosis may follow typhoid fever. In a large majority of such cases the
disease has been tuberculosis from the onset, which has begun with a low fever
and features suggestive of typhoid fever.
In epilepsy and in chronic chorea the fits and movements usually cease dur-
ing an attack, and in typhoid fever in a diabetic subject the sugar may be
absent during the height of the disease.
Varieties of Typhoid. — Typhoid fever presents an extremely complex symp-
tomatolog}^ Many forms have been described, some of which present exaggera-
tion of common s3"mptoms, others modification in the course, others again
greater intensity of action of the poison on certain organs. As we have seen,
when the nervous system is specially involved, it has been called the cerebro-
spinal form; when the kidneys are early and severely affected, nephro-typhoid ;
when the disease begins with pulmonary symptoms, pneumo-typhoid ; with
pleurisy, pleuro-typhoid ; when the disease is characterized throughout by pro-
fuse sweats, the sudoral form of the disease. It is enough to remember that
typhoid has no fixed and constant course, that it may set in occasionally with
symptoms localized in certain organs, and that many of its symptoms are
extremely variable — in one epidemic uniform and text-book-like, in another
slight or not met with. This diversified symptomatolog}^ has led to many
clinical errors, and in the absence of the salutary lessons of morbid anatomy
it is not surprising that practitioners have so often been led astray. We may
recognize with Murchison the following varieti':!S :
1. The mild and abortive forms. Much attention has been paid of late to
the milder varieties of t3^phoid fever — the typhus levissimus of Griesinger.
Woodruff, of the United States Arm3% has called special attention to the great
danger of neglecting these mild forms, which are often spoken of as mountain
fever and malarial fever, " acclimation," " ground," and " miasmatic " fevers.
During the prevalence of an epidemic there ma3' be cases of fever so mild that
the patient does not go to bed. The onset may be sudden, particularly in chil-
TYPHOID FEVER. 91
dren. The general symptoms are slight, the pulse rate not high, the fever
rarely above 102°. Eose spots are usually present, with splenic enlargement.
Diarrhoea is rare. The Widal reaction is present in a majority of the patients.
There may be a marked tendency to relapse. While infrequent, characteristic
complications and sequelae may give the first positive clue to the nature of the
trouble. J. B. Briggs has studied 44 of these mild cases from my clinic, in
which the fever lasted 14 days or less. Eose spots were present in 24, and the
Widal reaction in 26. There were three relapses. It can not be too forcibly
impressed upon the profession that it is just by these mild cases, to which so
little attention is paid, that the disease may be kept up in a community.
2. The grave form is usually characterized by high fever and pronounced
nervous symptorns. In this category, too, come the very severe cases, setting in
with pneumonia and Bright's disease, and with the very intense gastro-intestinal
or cerebro-spinal symptoms.
3. The latent or ambulatory form of typhoid fever, which is particularly
common in hospital practice. The symptoms are usually slight, and the patient
scarcely feels ill enough to go to bed. He has languor, perhaps slight diarrhoea,
but keeps about and may even attend to his work throughout the entire attack.
In other instances delirium sets in. The worst cases of this form are seen in
sailors, who keep up and about, though feeling ill and feverish. When brought
to the hospital they often have symptoms of a most severe type of the disease.
Hagmorrhage or perforation may be the first marked symptom of this ambula-
tory type. Sir W. Jenner has called attention to the dangers of this form, and
particularly to the grave prognosis in the case of persons who have travelled
far with the disease in progress.
Hemorrhagic Typhoid Fever. — This is excessively rare. Among Ouskow's
6,513 cases there were 4 fatal eases with general hsemorrhagic features. Only
three instances were present in our series. Haemorrhages may be marked from
the outset, but more commonly they come on during the course of the disease.
The condition is not necessarily fatal. Several of those reported by Nicholls
from the Eoyal Victoria Hospital, Montreal, recovered. (See Hamburger,
Studies III.)
An afebrile typhoid fever is recognized by authors. Liebermeister says that
the cases were not uncommon at Basel. The patients presented lassitude, de-
pression, headache, furred tongue, loss of appetite, slow pulse, and even the
spots and enlarged spleen. I have seen the temperature normal on the sixteenth
day, while the spots did not come out until later.
Typhoid Fever in Children. — Griffith collected a series of 325 cases in
children under two and a half years; 111 of these were in the first year. Out
of a total of 278 cases in which the result was recorded, 142 died. The cases
are not very uncommon. The high mortality in Griffith's paper was probably
due to the fact that only the more serious cases are reported. The abdominal
symptoms are usually mild; fatal haemorrhage and perforation are rare.
Among sequelae, aphasia, noma, and bone lesions are stated to be more common
in children than in adults. Two of our cases were under one year of age.
Typhoid Fever in the Aged. — After the sixtieth year the disease runs
a less favorable course, and the mortality is very high. The fever is not so
high, but complications are more common, particularly pneumonia and heart-
failure.
92 SPECIFIC INFECTIOUS DISEASES.
Typhoid Fever in Peegxaxct. — Pregnancy affords no immunity against
typhoid. In 1,500 of our cases to September 10, 190-i, 438 of which were
females, there were 6 cases. Goltdammer noted 26 pregnancies in 600 cases
of typhoid fever in the female. It is more commonly seen in the first half of
pregnancy. The pregnancy is interrupted in about 65 per cent of the cases,
iisually in the second week of the disease. In the obstetrical department of the
Johns Hopkins Hospital (J. W. Williams) there have been (to January,
1905) three cases of puerperal infection with bacillus typhosus. One case
showed a localized lesion of the chorion, from which cultures were obtained
(Little).
Typhoid Fever ix the Fcetus. — From the recent studies of Fordyce,
J. L. Morse, and F. W. L3Tich, we may conclude that the typhoid bacillus may
pass through the jjlacenta to the child, causing a typhoid septicasmia, without
intestinal lesions. Ljmch has recently collected 16 such cases. Infection of
the foetus does not necessarily follow, but when infected the child dies, either
in utero or shortly after birth. The Widal reaction has been obtained with
foetal blood. Its presence does not indicate that the child has survived infec-
tion in utero, as the agglutinating substances may filter through the placenta.
They may also be transmitted to the nursling through the milk, and cause a
transient reaction. The reaction could not be obtained with foetal blood from
Avhich typhoid bacilli were cultivated (Lynch).
Eelapse. — Eelapses vary in frequenc}^ in different epidemics, and, it would
appear, in different places. The percentages of different authors range from
3 per cent (Murchison), 11 per cent (Baumler), to 15 or 18 per cent (Immer-
mann). In 1,500 cases there were 172 relapses, 11.4 per cent.
We may recognize the ordinary, the intercurrent, and the spurious relapse.
The ordinary relapse sets in after complete defervescence. The average
duration of the interval in Irvine's cases was a little over five days.
In one of my cases there was complete apjTCxia for twenty-three days, fol-
lowed b}' a relapse of forty-one days' duration; then apyrexia for forty-two
days, followed by a second relapse of two weeks' duration. As a rule, two of
the three important symptoms — step-like temperature at onset, roseola, an
enlarged spleen — should be present to justify the diagnosis of a relapse. The
intestinal symptoms are variable. The onset may be abrupt with a chill, or
the temperature may have a typical ascent, as shown in Chart I. The number
of relapses range from 1 to 5. In a case at the Pennsylvania Hospital in 1904
the disease lasted eleven months and four days, during which there were six
relapses. The attack is usually less severe and of shorter duration. Of
Murchison's 53 cases, the mean duration of the -first attack was about twenty-
six days; of the relapse, fifteen days. The mortality of relapse cases is not
high.
The intercurrent relapse is common, often most severe, and is responsible
for a great man}^ of the most protracted cases. The temperature drops and
the patient improves; but after remaining between 100° and 102° for a
few days, the fever again rises and the patient enters upon another attack,
Avhich may be even more protracted, and of much greater intensity than the
original one.
Spurious relapses are very common. They have already been referred to
on page 72, under post-t}^hoid elevations of temperature. They are recrudes-
TYPHOID FEVER. 93
eenees of the fever due to a number of causes. It is not always easy to deter-
mine whether a relapse is present, particularly in cases in which the fever
persists for only five or seven days without rose-spots and without enlargement
of the spleen.
Undoubtedly a reinfection from within, yet of the conditions favoring the
occurrence of relapse we as yet know little. Durham has advanced an interest-
ing theory : Every typhoid infection is a complex phenomenon caused by groups
of bacilli alike in species but not identical, as shown by their serum reactions.
The antitoxin formed in the blood during the primary attack neutralizes only
one (or several) groups, the remaining groups still preserving their pathogenic
power. Following an error in diet, or some indiscretion, these latter groups
may multiply sufficiently to cause a reinfection. Multiple relapses may be-
similarly explained. Bacteriological proof of this interesting theory has not yet
been given.
Biagnosis. — There are several points to note. In the first place, typhoid
fever is the most common of all continued fevers. Secondly, it is extraordi-
narily variable in its manifestations. Thirdly, there is no such hybrid malady
as typho-malarial fever. Fourthly, errors in diagnosis are inevitable, even
under the most favorable conditions.
Data for Diagnosis. — (a) General. — IsTo single symptom or feature is
characteristic. The onset is often suggestive, particularly the occurrence of
epistaxis, and (if seen from the start) the ascending fever. The steadiness of
the fever for a week or longer after reaching the fastigium is an important
point. The irregular remittent character in the third week, and the intermit-
tent features with chills, are common sources of error. While there is nothing
characteristic in the pulse, dicrotism is so much more common early in typhoid
fever that its presence is always suggestive. The rash is the most valuable
single sign, and with the fever usually clinches the diagnosis. The enlarged
spleen is of less importance, since it occurs in all febrile conditions, but with
the fever and the rash it completes a diagnostic triad of the disease. The
absence of leucocytosis and the presence of Ehrlich's reaction are valuable acces-
sory signs.
(&) Specific. — (1) Isolation of TypJioid Bacilli from the Blood. — New
methods have given better results in this procedure, which has been carried out
extensively in my ward by Cole, and I can testify to its great value in doubtful
cases and in the acute septic forms. The hypodermic puncture of a vein for
the blood causes little or no pain.
(2) Isolation of Typhoid Bacilli from the Stools. — Cultures from the stools
have proved of diagnostic value. A new and very satisfactory method is that
of von Drigalski and Conradi (Zeit. f. Hygiene, Bd. 39), largely used in the
campaign against typhoid in Germany, with which those familiar with bac-
teriologic methods are able to isolate the bacilli in a majority of the cases.
(3) Isolation of Typhoid Bacilli from the Urine. — Neumann, Horton-
Smith, Eichardson, and Gwyn have shown the great frequency of typhoid bacilli
in the urine. In some cases they may be obtained before the Widal test is posi-
tive. Eoutine cultures do not offer great difficulties, and may frequently be
of diagnostic value.
(4) Isolation of Typhoid Bacilli from the Rose-spots. — Neufeld, Cursch-
mann, and Richardson have demonstrated the presence of the bacilli in rose-
94 SPECIFIC INFECTIOUS DISEASES.
spots in 32 of 40 cases examined. As the procedure causes considerable dis-
comfort it can not be used as a routine method.
(5) The Agglutination Test. — In 1894 Pfeiffer showed that cholera spirilla,
when introduced into the peritonaeum of an immunized animal, or when mixed
with the serum of immimized animals, lose their motion and break up. This
" Pfeiffer's phenomenon " of agglutination and immobilization was thoroughly
studied by Durham and also by A. S. Grlinbaum, and the specificity of the
reaction demonstrated. Widal took the method, and made it available in
clinical work.
Methods. — (a) Macroscopic or Slow Method. — This has not been largely
used in clinical work, but on the whole the results are probably more satisfactory
than with the microscopic method, and in hospitals, at least, the difficulties are
no greater. Lately the use of cultures of dead bacilli has received quite wide
application. This method is very satisfactory when the living, active bacilli
can not be conveniently employed.,
(6) Microscopic or Rapid Method. — The serum is mixed with a young
bouillon culture of the tj^phoid bacillus, or with a suspension of a young agar
culture, in such a manner as to dilute the serum to the required degree. A
hanging-drop preparation of the mixture is made, and if the reaction is posi-
tive the bacilli will within a given time lose their motility and collect in clumps.
Wyatt Johnston introduced the use of dried blood. It is convenient, but does
not permit accurate dilutions. The use of glass bulbs to obtain the serum, and
small glass pipettes to make accurate dilutions, is of value. As Cabot says,
" the test is a quantitative, not a qualitative, one." Both the degree of dilu-
tion and the time limit are of importance. A safe standard, and the one in
use at the Johns Hopkins Hospital, is a dilution of 1-50 and a time limit of
one hour.
Eesults. — Cabot's collection of 5,978 cases gives a positive reaction in 97.2
per cent. A positive reaction was obtained in 93 per cent of 849 cases tested
before the eighth day. It may not appear until the relapse. In 4 of my cases
it developed on the twenty-second, twenty-sixth, thirty-fifth, and forty-second
days, respectively. It may be present even twenty or thirty years subsequent
to the attack of fever.
While on the whole the serum reaction is of very great value, there are cer-
tain difficulties and objections which must be considered. A perfectly charac-
teristic case with hsemorrhages, rose-spots, etc., may give no reaction throughout.
In other cases the reaction is much delayed, becoming positive only during
convalescence, or even during a relapse. It must be borne in mind that occasion-
ally the reaction is not obtained with low dilutions, while with higher dilutions
the reaction is characteristic.
Common Sources op Eeeoe in Diagnosis. — An early and intense local-
ization of the infection in certain organs may give rise to doubt at first.
Cases coming on with severe headache, photophobia, delirium, twitching of
the muscles and retraction of the head are almost invariably regarded as cerebro-
spinal meningitis. Under such circumstances it may for a few days be impos-
sible to make a satisfactory diagnosis. I have thrice performed autopsies on
cases of this kind in which no suspicion of typhoid fever had been present, the
intense cerebro-spinal manifestations having dominated the scene. Until the
appearance of abdominal symptoms, or the rash, it may be quite impossible to
TYPHOID FEVER. 95
determine the nature of the case. Cerebro-spinal meningitis is, however, a
rare disease; typhoid fever a very common one, and the onset with severe
nervous symptoms is by no means infrequent. The lumbar puncture is now
a great help.
I have already spoken of the misleading pulmonary symptoms, which occa-
sionally occur at the very outset of the disease. The bronchitis rarely causes
error, though it may be intense and attract the chief attention. More difficult
are the cases setting in with chill and followed rapidly by pneumonia. I have
brought such a case before the class one week as typical pneumonia, and a fort-
night later shown the same case as undoubtedly one of typhoid fever. In
another case, in which the onset was with definite pneumonia, no spots were
present, and, though there were diarrhoea, meteorism, and the most pronounced
nervous symptoms, the doubt still remains whether it was a case of typhoid
fever or one of pneumonia in which severe secondary symptoms developed.
There is less danger of mistaking the pneumonia which occurs at the height
of the disease, and yet this is possible, as in a case admitted a few years ago
to my wards — a man aged seventy, insensible, with a dry tongue, tremor, ecchy-
moses upon the wrists and ankles, no rose-spots, enlargement of the spleen, and
consolidation of his right lower lobe. It was very natural, particularly since
there was no history, to regard such a case as senile pneumonia with profound
constitutional disturbance, but the autopsy showed the characteristic lesions of
typhoid fever. Early involvement of the pleura or the kidneys may for a time
obscure the diagnosis.
Of diseases with which typhoid fever may be confounded, malaria, certain
forms of pyaemia, acute tuberculosis, and tuberculous peritonitis are the most
important.
From malarial fever, typhoid is, as a rule, readily recognized. There is no
such disease as typho-malarial fever — that is, a separate and distinct malady.
Typhoid fever and malarial fever may coexist in the same patient. Of 1,500
cases of typhoid fever, in only three were the malarial parasites found in the
blood during the fever. In patients returning from Cuba and Porto Rico
during the late war the two conditions were often found together, but in this
country it is excessively rare. The term typho-malarial fever should be aban-
doned. The autumnal type of malarial fever may present a striking simi-
larity in its early days to typhoid fever. Differentiation may be made only
by the blood examination. There ma}^ be no chills, the remissions may be
extremely slight, there is a history perhaps of malaise, weakness, diarrhoea,
and sometimes vomiting. The tongue is furred and white, the cheeks flushed,
the spleen slightly enlarged, and the temperature continuous, or with very
slight remissions. The gestivo-autumnal variety of the malarial parasite may
not be present in the circulating blood for several days. Every year we had
one or two cases in which the diagnosis was in doubt for a few days.
Pycemia. — The long-continued fever of obscure, deep-seated suppuration,
without chills or sweats, may simulate typhoid. The more chronic cases of
ulcerative endocarditis are usually diagnosed enteric fever. The presence or
absence of leucocytosis is an important aid. The Widal reaction and the blood
cultures now offer additional and valuable help.
Acute miliary tuberculosis is not infrequently mistaken for typhoid fever.
The points in differential diagnosis will be discussed under that disease. Tuber-
96 SPECIFIC INFECTIOUS DISEASES.
culous peritonitis in certain of its forms may closely simiilate typhoid fever,
and "vrill be referred to in another section.
The early abdominal pain^ etc., may lead to the diagnosis of appendicitis.
(See Appendicitis.)
Prognosis. — (a) Death-rate. — The mortality is very variable, ranging in
private practice from 5 to 12 and in hospital practice from T to 20 per cent.
In some large epidemics the death-rate has been very low. In the Maidstone
epidemic it was between 7 and 8 per cent. In recent years the mortality from
tA'phoid fever has certainly diminished, and, nnder the influence of Brand, the
reintroduction of hydrotherapy has reduced the death-rate in institutions in a
remarkable manner, even as low as 5 or 6 per cent. Of the 1,500 cases treated
in my wards, 9.1 per cent died. The mortality in the Spanish- American War
was very low — T per cent — and may be attributed to the picked set of men and
to the care and attention which the patients received. In South Africa the
mortality- was 20.9 per cent to March 31, 1901.
(&) Special Features in Prognosis. — ^Unfavorable s^miptoms are high fever,
tosic symptoms with delirium, meteorism, and haemorrhage. Fat subjects
stand typhoid fever badly. The mortality in women is greater than in men.
The complications and dangers are more serious in the ambulatory form in
which the patient has kept about for a week or ten days. Early involvement
of the nervous system is a bad indication; and the low, muttering delirium
with tremor means a close fight for life. Prognostic signs from the fever alone
are deceptive. A temperature above 10-1° may be well borne for many days
if the nervous system is not involved.
(c) Sudden Death. — It is difficult in many cases to explain this most
lamentable of accidents in the disease. There are cases in which neither cere-
bral, renal, nor cardiac changes have been found; there are instances too in
which it does not seem likely that there could have been a special localization
of the toxins in the pneumogastric centres. McPhedran, in reporting a case
of the kind, in which the post mortem showed no adequate cause of death, sug-
gests that the experiments of McWilliam on sudden cardiac failure probably
explain the occurrence of death in certain of the cases in which neither em-
bolism nor uraemia is present. Under conditions of abnormal nutrition there
is sometimes induced a state of delirium cordis, which may occur spontane-
ously, or, in the case of animals, on slight irritation of the heart, with the result
of extreme irregularity and finally failure of action. Sudden death occurs
more frequently in men than in women, according to Dewevre's statistics, in
a proportion of 114 to 26. It may occur at the height of the fever, and, as
pointed out by Graves, may also happen during convalescence. There were
four cases in my series.
Prophylaxis. — In cities the prevalence of typhoid fever is directly propor-
tionate to the inefficiency of the drainage and the water-supply. With their
improvement the mortality has been reduced one-half or even more. Fulton
has shown that in the United States, at least, the disease exists to a propor-
tionately greater extent in the country than it does in the city, and that the
propagation of this disease is in general from the country to the town. In the
water-supply of the latter the chances for dilution of the contaminating fluids
are so much greater than in the country, where the privy vault is often in
such close proximit}' to the well.
TYPHOID FEVER. 97
But it is not only through water that the disease is transmitted. Other
methods play an important though not so frequent role. The bacilli may be
carried by milk, oysters, uncooked vegetables, etc. Flies play an important
role in the spread of the disease. Many cases undoubtedly arise by direct
infection. But through whatever channel the infection occurs, for new cases
to arise the virus must be obtained from another patient. It has been dem-
onstrated by Jordan, Eussell, Zeit and others that under ordinary circum-
stances the bacilli do not live and thrive long outside the body. To stamp out
typhoid fever requires (1) the recognition of all cases, including the typhoid
carriers, and (2) the destruction of all typhoid bacilli as they leave the patient.
It is as much a part of the physician's duty to look after these points as to
take care of the patient. Mild cases of fever are to be regarded with suspicion.
From the standpoint of prophylaxis, the question practically narrows down
to disinfection of the urine, stools, sputum . ( in the few cases where bacilli are
present), and of objects which may accidentally be contaminated by these
excretions.
The nurse or attendant should be taught to regard every specimen of urine
as a pure culture of typhoid bacilli, and to exercise the greatest care in pre-
venting the scattering of drops of urine over the patient, bedding or floor, or
over the hands of the attendant.
To disinfect the urine the best solutions are carbolic acid, 1-30, _ in an
amount equal to that of the urine, or bichloride of mercury, 1-1,000, in an
amount one-fifteenth that of the fluid to be sterilized. These mixtures with
the urine should stand at least two hours.
Urotropin causes disappearance of the bacilli from the urine when bacil-
luria is present, but under no circumstances should its administration permit
the disinfection of the urine to be neglected.
To disinfect stools carbolic acid is the most useful. It is cheap, and efficient
when used in strong solutions. The stool should be mixed with at least twice
its volume of 1-20 carbolic-acid solution and allowed to stand for several hours.
With hydrotherapy the disinfection of the bath water after use offers a seri-
ous and somewhat difficult problem.
E. Babucke has sought experimentally the best method for the disinfec-
tion of the bath water. He found chloride of lime the best substance to use,
and- found that even where the water contains coarse fecal matter, '250 gm.
(one-half pound) of chloride of lime will render the ordinary bath of 200
litres sterile in one-half hour.
If there be any expectoration, the sputum should receive the same care as
in tuberculosis. It is best to collect it in small cloths, which may be burned.
All the linen leaving the patient's bed or person should be soaked for two
hours in 1-20 carbolic-acid solution, and then sent to the laundry, where it
should be boiled. All dishes should be boiled before leaving the patient's room.
The nurse should wear a rubber apron when giving tubs or working over
a typhoid patient, and this should be washed frequently with a carbolic acid
or bichloride of mercury solution. The nurse should wear rubber gloves when
giving tubs, or else soak her hands thoroughly in 1-1,000 bichloride solution,
after she has finished.
It is impossible here to deal with all the possible modes of spread of 'the
infection. Keeping in mind that everything leaving the patient should be
98 SPECIFIC INFECTIOUS DISEASES.
sterilized whenever there is a chance of its having been contaminated by the
discharges, a nurse of ordinary intelligence, even one of the family, can carry
-out very satisfactory prophylaxis.
Should the typhoid fever patient be isolated? To prevent direct infection
of other members of the family a moderate degree of isolation should be car^
ried out, though this need not be absolute as in the exanthemata. The win-
dows should have fly screens in summer. After recovery the room should be
disinfected.
An important question is as to the necessity for the isolation of typhoid
patients in special wards in hospitals. At present this is not generally done in
the United States. When, however, in a hospital with as good sanitary arrange-
ments as the Johns Hopkins possesses, and in vfhich all possible precautions
are taken to prevent the infection spreading from patient to patient, 1.81 per
cent of all the cases have been of hospital origin, the advisability of isolation
of typhoid fever patients is certainly worth considering. On the other hand,
in the general hospital, with students in the wards, the cases are more thor-
oughly studied, and in the graver complications, as perforation, it is of the
greatest advantage to have the early co-operation of the house surgeon.
During the past few years an active campaign has been started in Ger-
many, under the leadership of Professor Koch, with the object of ultimately
stamping out this disease by means of early diagnosis and the institution of
rigid measures for j)reventing the distribution of the infecting agent from the
patients so diagnosed. With a corps of assistants he fitted up a laboratory in
Trier, a localit}'^ where the disease had a firm hold. By bacteriological methods
he was able to demonstrate that 72 persons were suffering from typhoid infec-
tion. So soon as the nature of a case was established, isolation and vigorous
disinfection were practiced. The result was that within three months no more
typhoid bacilli were discoverable, the patients were cured, no fresh cases arose,
and, so far as that group of villages was concerned, typhoid was exterminated.
Since, in other groups of villages situated under strictly comparable conditions,
but where these methods of dealing with the disease were not practiced, typhoid
continues to be prevalent, it may reasonably be inferred that the disappearance
at Trier was not spontaneous, but due to the methods of identification and dis-
infection which were used.
When epidemics are prevalent the drinking-water and the milk used in
families should be boiled. Travellers should drink light wines or mineral
water rather than ordinary water or milk. Care should be taken to thor-
oughly cook oysters which have been fattened or freshened in streams con-
taminated with sewage.
While in camps it is easy to boil and filter the water; with troops on
the march it is a very different matter, and it is impossible to restrain men
from relieving their thirst the moment they reach, water. Various chemical
methods have been recommended — the use of bromine, hypochlorite of lime,
permanganate of potassium, and the tablets of sodium bisulphate, none of
which are probably very satisfactory.
Vaccination. — A. E. Wright has introduced a method of vaccination
against typhoid. A full description of the principles involved, as well as of the
technique, is given in his work, A Short Treatise on Anti-Typhoid Inoculation,
London, 1901. The material used is a bouillon culture of virulent bacilli
TYPHOID FEVER. 99
heated to 60° in order to kill them. By a somewhat complicated procedure the
number of bacteria in this culture is estimated, and for the first inoculation
a quantity of the vaccine containing 750 to 1,000 millions of bacteria is
employed, and for the second inoculation a quantity containing 1,500 to
2,000 millions of bacilli is employed. Two inoculations are given at an
interval of about two weeks. Following inoculation there is a mild local
reaction and constitutional symptoms begin within two or three hours. As
a sequence of the injection, there is an increase in both the bactericidal
and agglutinating powers of the blood. Many thousand inoculations have
now been made under Wright's direction, mainly on the British troops in
India and South Africa. From the statistics so far available he concludes
that the incidence of typhoid fever was diminished by at least one-half in
the inoculated, while in the aggregate the proportion of deaths to cases among
the inoculated has been rather less than half that among the uninoculated.
The evidence so far points to a persistence of the protective effect for at least
two years after inoculation. Wright's conclusions are supported by the evi-
dence of a large number of English army officers. Wherever, therefore, large
bodies of persons are likely to be exposed to unusual dangers of infection the
procedure may be employed.
Treatment. — {a) Geneeal Management. — The profession was long in
learning that typhoid fever is not a disease to be treated mainly with drugs.
Careful nursing and a regulated diet are the essentials in a majority of the
cases. The patient should be in a well-ventilated room (or in summer out
of doors during the day), strictly confined to bed from the outset, and there
remain until convalescence is well established. The bed should be single, not
too high, and the mattress should not be too hard. The woven wire bed, with
soft hair mattress, upon which are two folds of blanket, combines the two
great qualities of a sick-bed, smoothness and elasticity. A rubber cloth should
be placed under the sheet. An intelligent nurse should be in charge. When
this is impossible, the attending physician should write out specific instruc-
tions regarding diet, treatment of the discharges, and the bed-linen,
(&) Diet. — Milk, eggs, and water are the essential foods during the
febrile period. An adult receives four ounces of milk, diluted with two ounces
of lime-water or soda-water, every four hours ; and four ounces of albumen-
water, made from the white of one or two eggs, every four hours. In this
way he is fed every two hours. The juice of half a lemon or an ounce of
fresh orange juice is added to the albumen-water, which may be sweetened
with a little sugar. The great majority of our patients have this diet alone
during the fever. Whey is substituted for the milk i"f there are curds in
the stools or if there is much distention or if the plain milk disagrees in
any way. If necessary, milk is cut off altogether and the albumen-water
increased. Buttermilk, boiled milk, koumiss, or peptonized milk may be
used. The beef extracts, meat juices, and artificially prepared foods are
unnecessary, and in private practice among people in moderate circumstances
add greatly to the expense of the illness. Such a diet is simple, reduces the
work of feeding to a minimum, and agrees with a great majority of all
patients. Water is given at fixed intervals. A good plan is to have a jug
of water beside the patient and a tubing with a glass mouth-piece, so that he
can drink as much as he wishes. A washing-out plan of treatment is advised
100 SPECIFIC INFECTIOUS DISEASES.
by E. W. Gushing and T. W. Clarke, of the Lake-side Hospital, Cleveland.
A gallon or more may be taken in the day. The water causes polyuria, and is
a sort of internal hydrotherapy by which the toxins may be washed out.
Barley water, lemonade, or iced-tea may be used. A small cup of coffee in the
morning is very grateful. Bouillon or strained vegetable soup may serve as a
change. Ice cream ma}' be taken at any time, and is an agreeable variation,
particularly for children.
It is possible that we give too much food. Of late years the disease has
been treated by what has been called therapeutic fasting — ^little or no food,
only water.
Alcohol is unnecessary in a great majority of the cases. Of late years
I have used it much less freely; but when the heart is feeble and the toxic
symptoms are severe, eight to twelve ounces of whisky may be given in the
twenty- four hours.
(c) Htdeotherapy. — The use of water, inside and outside, was no new
treatment in fevers at the end of the eighteenth century, when James Currie
(a friend of Burns and the editor of his poems) wrote his Medical Reports
on the Effects of Water, Cold and Warm, as a Eemedy in Fevers and other
Diseases. In this country it was used with great effect and recommended
strongly by Xathan Smith, of Yale. Since 1861 the value of bathing in
fevers has been specially emphasized by the late Dr. Brand, of Stettin.
Hydrotherapy may be carried out in several different ways, of which,
in typhoid fever, the most satisfactorv are sponging, the wet pack, and the
full bath.
(a) Cold Sponging. — The water may be tepid, cold, or ice-cold, according
to the height of the fever. A thorough sponge-bath should take from fifteen
to twenty minutes. The ice-cold sponging is not quite as formidable as the
full cold bath, for which, when there is an insuperable objection in private
practice, it is an excellent alternative. But frequently it is difficult to get
the friends to appreciate the advantages of the sponging. When such is the
case, and in children and delicate persons, it can be made a little less for-
midable by sponging limb by limb and then the back and abdomen.
(&) The cold pacTv is not so generall}^ useful in typhoid fever, but in
eases with very pronounced nervous symptoms, if the tub is not available,
the patient may be wrapped in a sheet wrung out of water at 60° or 65°, and
then cold water sprinkled over him with an ordinary watering-pot.
(c) The Bath. — The tub should be long enough so that the patient can
be completely covered except his head. Our rule for some years has been
to give a bath at 70° every third hour when the temperature was above 103.5°.
The patient remains in the tub for fifteen or twenty minutes, is taken out,
wrapped in a dry sheet, and covered with a blanket. Wliile in the tub the
limbs and trunk are rubbed thoroughly, either with the hand or with a suit-
able rubber. It is well to give the first one or two baths at a temperature
of 80° or 85°. There is no routine temperature. If the bath at 70° is not
well taken, raise the temperature to 75° or 80°. It is important to see that
the canvas supports are properly arranged, and that the rubber pillow is com-
fortable for the patient's head. The first bath should not be given at night,
and it should be superintended by the house-physician. The amount of com-
plaint made by the patient is largely dependent upon the skill and care with
TYPHOID FEVER.
101
which the baths are given. Food is usually given, sometimes a stimulant,
after the bath. The blueness and shivering, which often follow the bath,
are not serious features. The rectal temperature is taken immediately after
the bath, and again three-quarters of an hour later. Contra-indications are
peritonitis, hasmorrhage, phlebitis, severe abdominal pain, and great pros-
tration. The accompanying chart (Chart V) shows the number of baths
June li
Temp
109
108
107
IOC
lOS
m
103
102
101
100
99
08
97
96
Temp
Pulse
Resp
Stoois
Day of yj
Disease.
M G H
, n 20 ■!, 28 24 24 „ 1 3 j S M
I I
Chart V.
and the influence on the fever during two days of treatment. The good
effects of the baths are : (1) The effect on the nervous system. The delirium
lessens, the tremor diminishes, and the toxic features are less marked. The
excretion of the toxins by the kidneys is stimulated. (2) The fever is re-
duced, though this is not the chief effect of the tubs ; indeed at the height of
the disease there may be very little reduction. (3) The heart rate usually
falls, the pulse becomes smaller and harder, and the blood pressure rises 15
or 20 mm. of Hg. (4) With hydrotherapy the initial bronchitis is bene-
fited, and there is less chance of passive congestion of the bases of the lungs.
(5) The liability to bed-sores is diminished and the frequent cleansing of the
skin is beneficial. Should boils occur, one bath-tub should be used for that
patient alone. (6) The mortality is reduced. In general hospitals from
six to eight patients in every hundred are saved by this plan of treatment.
At the Brisbane Hospital, where F. E. Hare used it so thoroughly, the mortal-
ity was reduced from 14.8 per cent to 7.5. There is a remarkable uniformity
in the death-rate of institutions using the method — usually from 6 to 8 per
102 SPECIFIC INFECTIOUS DISEASES.
cent. At the Eoyal Victoria Hospital, Montreal, the rate for the six years
was 5.4 per cent. At the Johns Hopkins Hospital the mortality among 1,500
cases was 137, or 9.1 per cent.
(d) Medicinal Treatment. — In hospital practice medicines are not
often needed. A great majority of my cases do not receive a dose. In private
practice it may be safer, for the young practitioner especially, to order a
mild fever mixture. The question of medicinal antipyretics is important:
they are used far too often and too rashly in typhoid fever. An occasional
dose of antifebrin or antipyrin may do no harm, but the daily use of these
drugs is most injurious. Quinine in moderate doses is still much employed.
The local use of guaiacol on the skin, 3ss. painted on the flank, causes a prompt
fall in the temperature.
In the various antiseptic drugs which have been advised I have no faith.
Most of them do no harm, except that in private practice their use has too
often diverted the practitioner from more rational and safer courses.
(e) Serum Therapy. — Numerous attempts have been made to obtain
specific sera, which have been of two varieties, bactericidal and antitoxic.
As Wasserman has shown, the probable reason why the former have failed
is owing to the lack of sufficient complement in the patient's blood, and at
present no available method has been found to increase this complement.
As the isolation of a soluble typhoid toxin has presented insuperable difficul-
ties so far, it is questionable whether an antitoxin of any value has yet been
obtained. With the reported isolation of typhoid toxins of considerable
strength by Conradi, and also by Macfadyen, it is possible that in the near
future an antitoxin serum of great value may be produced. One of the most
important problems in connection with this disease is the isolation of a strong
soluble toxin, the results of which would probably be very far-reaching.
Chantemesse (Presse Med., 1904, jSTo. 86) has published the results obtained
in several of the Paris hospitals with an antitoxic serum. The toxin is
obtained in the filtered cultures of typhoid bacilli grown on a medium con-
taining splenic pulp and human defibrinated blood. By injection of this into
horses a serum has been produced, which, during a period of three and a half
years, has been employed in the treatment of 765 cases, 545 by Chantemesse
himself, and 220 cases in children by Josias and Brunon. Of these 765 cases
only 30 died, a mortality of about 4 per cent, while in the other Paris hos-
pitals during the same period there occurred a mortality of 18 per cent, in
none of them under 12 per cent.
A third method is by means of the so-called extract of Jez, by the use of
which good results have been reported by Eichhorst and others, though so
far on a relatively small number of cases. This extract is obtained from
the bone-marrow, spleen, thymus, brain, and spinal cord of animals highly
immunized to typhoid bacilli. Large amounts must be used. Eemember-
ing the considerable period of time after the discovery of the diphtheria anti-
toxin before a serum of high value was obtained, it is not too much to hope
that some of these experiments may lead to important results.
(/) Treatment of the Special Symptoms. — The abdominal pain and
tympanites are best treated with fomentations or turpentine stupes. The
latter, if well applied, give great relief. Sir William Jenner used to lay
great stress on the advantages of a well-applied turpentine stupe. He
TYPHOID FEVER. 103
directed it to be applied as follows: A flannel roller was placed beneath the
patient, and then a double layer of thin flannel, wrung out of very hot water,
with a drachm of turpentine mixed with the water, was applied to the abdo-
men and covered with the ends of the roller. When the gas is in the large
bowel, a tube may be passed or a turpentine enema given. For tympanites,
with a dry tongue, turpentine may be given, or the oil of cinnamon, T(l iii-v,
every two hours (Caiger). If whey and albumen-water are substituted for
milk, the distention lessens. Charcoal, bismuth, )8-naphthol, and eserine,
•^ gr. hypodermically, may be tried. Opium should not be given.
For the diarrhoea, if severe — that is, if there are more than three or four
stools daily — a starch and opium enema may be given; or, by the mouth, a
combination of bismuth, in large doses, with Dover's powder; or the acid
diarrhoea mixture, acetate of lead (gr. ii), dilute acetic acid (tti, xv-xx)^
and acetate of morphia (gr. ^— |). The amount of food should be reduced,
and whey and albumen-water in small amounts be substituted for the milk.
An ice-bag or cold compresses relieve the soreness which sometimes accom-
panies the diarrhoea.
Constipation is present in many cases, and though I have never seen it
do harm, yet it is well every third or fourth day to give an Ordinary enema.
If a laxative is needed during the course of the disease, the Hunyadi-janos
or Friedrichshall water may be given.
Hcemorrhage. — As absolute rest is essential, the greatest care should be
taken in the use of the bed-pan. It is perhaps better to allow the patient to
pass the motions into the draw-sheet. Ice may be given, and a light ice-bag
placed on the abdomen. The amount of food should be restricted for eight
or ten hours. If there is a tendency to collapse, stimulants should be given,
and, if necessary, hypodermic injections of ether. Injection of salt solu-
tion beneath the skin or directly into a vein may revive a failing heart. Tur-
pentine is warmly recommended by certain authors. Should opium be given ?
One-fifth of the cases of perforation occur with haemorrhage, and the opium
may obscure the features upon which alone the diagnosis of perforation may
be made. Of late we have abandoned the use of opium and have given the
calcium chloride or lactate in doses of gr. xv every four hours. Gelatine we
have also used a good deal, but it seems of doubtful value.
Perforation and Peritonitis. — Early diagnosis and early operation mean
the saving of one-third of the cases of this heretofore uniformly fatal com-
plication. The aim should be to operate for the perforation, and not to wait
until a general peritonitis diminishes by one-half the chances of recovery.
An incessant, intelligent watchfulness on the part of the medical attendant
and the early co-operation of the surgeon are essentials. Every case of more
than ordinary severity should be watched with special reference to this com-
plication. Thorough preparation by early observation, careful notes, and
knowledge of the conditions will help to prevent needless exploration. No
case is too desperate; we have had one recovery after three operations.
Twenty cases of perforation in my series were operated upon with seven
recoveries; in an eighth case the patient died of the toxaemia on the eighth
day after the laparotomy. The figures now published give from 25 to 33 per
cent of recoveries. In doubtful cases it is best to operate, as experience
shows that patients stand an exploration very well.
104 SPECIFIC INFECTIOUS DISEASES.
Cholecystitis. — A majority of the cases recover, but if the symptoms are
very severe and progressive, operation should be advised.
Bone Lesions. — The typhoid periostitis of the ribs or of the tibia does
not always go on to suppuration, though, as a rule, it requires operation.
Unless the practitioner is accustomed to do very thorough surgical work,
he should hand over the patient to a competent surgeon, who vidll clear out
the diseased parts with the greatest thoroughness. Eecurrence is inevitable
unless the operation is complete.
For the progressive Jieart-wealcness, alcohol, strychnine and ether hypo-
dermically in full doses, digitalis, and the saline infusions may be tried.
The nervous symptoms of typhoid fever are best treated by hydrother-
apy. Special advantages of this plan are that the restlessness is allayed,
the delirium quieted, and sedatives are rarely needed. In the cases which
set in early with severe headache, meningeal symptoms, and high fever, the
cold bath, or in private practice the cold pack, should be employed. An
ice-cap may be placed on the head, and if necessary morphia administered
hypodermically. For the nocturnal restlessness, so distressing in some cases,
Dover's powder should be given. As a rule, if a hypnotic is indicated, it is
best to give opium in some form. Pulmonary complications should, if severe,
receive appropriate treatment.
Bacilluria. — When bacilli are present, as demonstrated by cultures or
shown by the microscope, urotropin may be given in ten-grain doses and kept
lip, if necessary, for several weeks. A patient should not be discharged with
bacilli in his urine.
In protracted cases very special care should be taken to guard against hed-
■ sores. Absolute cleanliness and careful drjdng of the parts after an evacua-
tion should be enjoined. The patient should be turned from side to side and
propped with pillows, and the back can then be sponged with spirits. On the
first appearance of a sore, the water- or air-bed should be used.
{(j) The Management of Convalescence. — Convalescents from typhoid
fever frequently cause greater anxiety than patients in the attack. The ques-
tion of food has to be met at once, as the patient acquires a ravenous appetite
and clamors for a fuller diet. My custom has been not to allow solid food
until the temperature has been normal for ten days. This is, I think, a safe
rule, leaning perhaps to the side of extreme caution ; but, after all, with eggs,
milk toast, milk puddings, and jellies, the j)atient can take a fairly varied
diet. Many leading practitioners allow solid food to a patient so soon as he
desires it. Peabody gives it on the disappearance of the fever ; the late Austin
Flint was also in favor of giving solid food early. I had a lesson in this
matter which I have never forgotten. A young lad in the Montreal General
Hospital, in whose case I was much interested, passed through a tolerably
sharp attack of typhoid fever. Two weeks after the evening temperature had
been normal, and only a day or two before his intended discharge, he ate
several mutton chops, and within twenty-four hours was in a state of col-
lapse from perforation. A small transverse rent was found at the bottom
of an ulcer which was in process of healing. It is not easy to say why solid
food, particularly meats, should disagree, but in so many instances an indis-
cretion in diet is followed by slight fever, the so-called fehris carnis, that it
is in the best interests of the patient to restrict the diet for some time after
TYPHUS FEVER. 105
the fever has fallen. Whether an error in diet may cause relapse is doiibt-
ful. The patient may be allowed to sit up for a short time about the end of
the first week of convalescence, and the period may be prolonged with a
gradual return of strength. He should move about slowly, and when the
weather is favorable should be in the open air as much as possible. He
should be guarded at this period against all unnecessary excitement. Emo-
tional disturbance not infrequently is the cause of recrudescence of the fever.
Constipation is not uncommon in convalescence and is best treated by
enemata. A protracted diarrhoea, which is usually due to iilceration in the
colon, may retard recovery. In such cases the diet should be restricted to
milk, and the patient should be confined to bed; large doses of bismuth and
astringent injections will prove useful. The recrudescence of the fever does
not require special measures. The treatment of the relapse is essentially that
of the original attack.
Post-typhoid insanity requires the judicious care of an expert. The
cases usually recover. The swollen leg after phlebitis is a source of great
worry. A bandage should be worn during the day or a well-fitting elastic
stocking. The outlook depends on the completeness with which the col-
lateral circulation is established. In a good many cases there is permanent
disability.
The post-typJioid neuritis, a cause of much alarm and distress, usually
gets well, though it may take months, or even a couple of years, before the
paralysis disappears. After the subsidence of the acute symptoms systematic
massage of the paralyzed and atrophic muscles is the most satisfactory
treatment.
The condition spoken of as the typhoid spine may drag on for months
and prove very obstinate. The neurotic state has to be treated. Separa-
tion from solicitous and sympathetic friends, hydrotherapy in the form of
the wet pack, and the Paquelin cautery are the most efficacious means of
cure. An encouraging prognosis may be followed by rapid improvement.
II. TYPHUS FEVER.
Definition. — An acute infectious disease of unknown origin, highly con-
tagious, characterized by sudden onset, maculated r^sh, marked nervous symp-
toms, and a cyclical course terminating by crisis, usually about the end of the
second week. Post mortem there are no special lesions other than those asso-
ciated with fever.
The disease is known by the names of hospital fever, spotted fever, jail
fever, camp fever, and ship fever, and in Germany is called exanthematic
typhus, in contradistinction to abdominal typhus.
Etiology. — Typhus fever has been one of the great epidemics of the world.
Until the middle of the nineteenth century it prevailed extensively in all the
larger cities of Europe, and at times extended to wide-spread outbreaks. As
Hirsch has remarked, " The history of typhus is written in those dark pages
of the world's story which tell of the grievous visitations of mankind by war,
famine, and misery of every kind." Few countries have suffered more than
Ireland, particularly between the years 1817 and 1819 and in 1846. In Eng-
106 SPECIFIC INFECTIOUS DISEASES.
land the disease has progressively diminished in intensity. In 1875 there were
1,499 deaths, in 1895 only 58 deaths. In 1897 there were only 3 cases of typhus
fever in the London Fever Hospitals. In England and Wales the disease has
steadily diminished. In 1883 there were 877 deaths; in 1903, 61 deaths. Of
late years the name typhus has not appeared in the Registrar-G-eneral Report
for England and Wales. The last really great epidemic was in the Turko-
Eussian War in 1877-'78.
The gradual disappearance of typhus fever is one of the great triumphs of
modern medicine. At present the disease lurks in only a few centres in Great
Britain and on the Continent, and every few years slight outbreaks occur in
larger cities, and sporadic cases appear from time to time. In the United
States typhus fever has not prevailed as an extensive epidemic for many years.
There were small epidemics in New York in 1881-'82 and in 1892-'93, and in
1883 in Philadelphia. A remarkable feature is the occurrence of a few cases
at long intervals of time from any other outbreaks, and at great distances from
any known foci of the disease. This was one of the points which led Murchi-
son to the belief that under favorable conditions it might originate spontane-
ously. Two small groups of cases of this nature have come under my observa-
tion. In 1877 there occurred a local outbreak at the House of Refuge, in
Montreal, a city in which the disease had not existed for many years. The
overcrowding was so great in the basement rooms of the refuge that at night
there were not more than 88 cubic feet of space to each person. Eleven indi-
viduals were affected. It was not possible to trace the source of infection.
In the spring of 1901 from one house three cases of fever were admitted
to my wards, which were regarded at first as typhoid fever, but the features were
so anomalous that our suspicions were aroused. The rash was perfectly char-
acteristic of typhus, the Widal reaction was negative, blood cultures were nega-
tive, and a post-mortem on one fatal case showed no typhoid lesions, and no
cultures were obtained from the spleen or the blood post-mortem. The other
two cases terminated by crisis, so that I think there can be no question that
the cases were typhus fever. The disease has not prevailed in Baltimore for more
than a quarter of a century. The patients were Lithuanians, they lived under
most unsanitary conditions, and were workers at a suburb frequented by a great
many foreigners from the eastern parts of Europe. The origin of the outbreak
could not be traced, nor did any other cases occur.
Typhus is one of the most highly contagious of febrile affections. In epi-
demics, nurses and doctors in attendance are almost invariably attacked. There
is no disease which has had so many victims in the profession. It is stated
that in a period of twenty-five years, among 1,230 physicians attached to institu-
tions in Ireland, 550 succumbed to this disease. Casual attendance upon cases
in limited epidemics does not appear to be very risky, but when the sick are
aggregated in wards the poison appears concentrated and the danger of infec-
tion is much enhanced. Bedding and clothes retain the poison for a long time.
Murchison thought that the virus was thrown off from the lungs and from the
skin. It attaches itself particularly to the clothing and linen and to the furni-
ture of the room, and appears to retain its activity for a remarkably long time.
To catch the disease there apparently must be fairly intimate contact with the
patient, more particularly contact with a large number of patients. Thus in
mild outbreaks of only a few cases physicians and nurses are rarely affected.
TYPHUS FEVER. 107
while in severe epidemics all in attendance may be attacked. Nothing has yet
been determined as to the nature of the specific virus.
Morbid Anatomy. — The anatomical changes are those which result from
intense fever. The blood is dark and fluid ; the muscles are of a deep red color,
and often show a granular degeneration, particularly in the heart ; the liver is
enlarged and soft and may have a dull clay-like lustre ; the kidneys are swollen ;
there is moderate enlargement of the spleen, and a general hyperplasia of the
lymph-follicles. Peyer's glands are not ulcerated. Bronchial catarrh is usu-
ally, and hypostatic congestion of the lungs often, present. The skin shows
the petechial rash.
Symptoms. — Incubation. — This is placed at about twelve days, but it may
be less. There may be ill-defined feelings of discomfort. As a rule, however,
the invasion is abrupt and marked by chills or a single rigor, followed by fever.
The chills may recur during the first few days, and there is headache with pains
in the back and legs. There is early prostration, and the patient is glad to
take to his bed at once. The temperature is high at first, and may attain its
maximum on the second or third day. The pulse is full, rapid, and not so
frequently dicrotic as in typhoid. The tongue is furred and white, and there
is an early tendency to dryness. The face is flushed, the eyes congested, and
the expression dull and stupid. Vomiting may be a distressing symptom. In
severe cases mental symptoms are present from the outset, either a mild febrile
delirium or an excited, active, almost maniacal condition. Bronchial catarrh
is common.
Stage of Eruption. — From the third to the fifth day the eruption appears
— first upon the abdomen and upper part of the chest, and then upon the
extremities and face; occurring so rapidly that in two or three days it is all
out. There are two elements in the eruption : a subcuticular mottling, " a
fine, irregular, dusky red mottling, as if below the surface of the skin some
little distance, and seen through a semi-opaque medium" (Buchanan) ; and
distinct papular rose-spots which change to petechise. In some instances the
petechial rash comes out with the rose-spots. Collie describes the rash as con-
sisting of three parts: rose-colored spots which disappear on pressure, dark-
red spots which are modified by pressure, and petechias upon which pressure
produces no effect. In children the rash at first may present a striking resem-
blance to that of measles, and give as a whole a curiously mottled appearance to
the skin. The term mulberry rash is sometimes applied to it. In mild cases the
eruption is slight, but even then is largely petechial in character. As the rash is
hasmorrhagic, it does not disappear after death. Usually the skin is dry, so that
sudaminal vesicles are not common. It is stated by some authors that a distinc-
tive odor is present. During the second week the general symptoms are much
aggravated. The prostration becomes more marked, the delirium more intense,
and the fever rises. The patient lies on his back with a dull expressionless face,
flushed cheeks, injected conjunctivae, and contracted pupils. The pulse increases
in frequency and is feebler; the face is dusky, and the condition becomes more
serious. Eetention of urine is common. Coma-vigil is frequent, a condition
in which the patient lies with open eyes, but quite unconscious ; with it there
may be subsultus tendinum and picking at the bedclothes. The tongue is dry,
brown, and cracked, and there are sordes on the teeth. Kespiration is accel-
erated, the heart's action becomes more and more enfeebled, and death takes
108 SPECIFIC INFECTIOUS DISEASES.
place from eshaiisTion. In favorable cases, about the end of the second week
occurs the crisis, in "n'hich, often after a deep sleep, the patient awakes feeling
much better and with a clear mind. The temperature falls, and although the
prostration may be extreme, convalescence is rapid and relapse very rare. This
abrupt termination by crisis is in striking contrast to the mode of termination
in typhoid fever.
Fever. — The temperature rises steadily during the first four or five days,
and the morning remissions are not marked. The maximum is usually attained
by the fifth day, when the temperature may be 105°, 106'', or 107°. In mild
cases it seldom rises above 103°. After reaching its maximum the fever gen-
erally continues with slight morning remissions until the twelfth or fourteenth
day, when the crisis occurs, during which the temperature may fall below nor-
mal within twelve or twentv^-four hours. Preceding a fatal termination, there
is usually a rapid rise in the fever to 108° or even 109°.
The heart may early show signs of weakness. The first sound becomes
feeble and almost inaudible, and a systolic murmur at the apex is not infre-
quent. Hypostatic congestion of the lungs occurs in all severe cases. The
brain symjjtoms are usually more pronounced than in typhoid, and the delirium
is more constant. A slight leucocytosis is more common than in typhoid.
The urine in typhus shows the usual febrile increase of urea and uric acid.
The chlorides diminish or disappear. Albumin i^ present in a large proportion
of the cases, but nephritis seldom occurs.
Variations in the course of the disease are naturally common. There are
malignant cases which rapidly prove fatal within two or three days; the
so-called typhus siderans. On the other hand, during epidemics there are
extremely mild cases in which the fever is slight, the delirium absent, and con-
valescence is established by the tenth day.
CoMPLiCATioxs AXD SEQUELS. — Bronclio-pneumonia is perhaps the most
common complication. It may pass on to gangrene. In certain epidemics
gangrene of the toes, the hands, or the nose, and in children noma or cancrum
oris, have occurred. Meningitis is rare. Paralyses, which are probably due
to a post-febrile neuritis, are not very uncommon. Septic processes, such as
parotitis and abscesses in the subcutaneous tissues and in the joints, are occa-
sionally met with. Xephritis is rare. Htematemesis may occur.
Prognosis. — The mortality ranges in difEerent epidemics from 12 to 20 per
cent. It is very slight in the young. Children, who are quite as frequently
attacked as adults, rarely die. After middle age the mortality is high, in some
epidemics 50 per cent. Death usually occurs toward the close of the second
week and is due to the toxemia. In the third week it more commonly results
from pneumonia.
Diagnosis. — During an epidemic there is rarely any doubt, for the disease
presents distinctive general characters. Isolated cases may be very difficult to
distinguish from typhoid fever. "While in typical instances the eruption in
the two affections is very difEerent, yet taken alone it may be deceptive, since
in typhoid fever a roseolous rash may be abundant and there may be occasion-
ally a subcuticular mottling and even petechiEe. The difference in the onset,
particularly in the temperature, is marked; but cases in which it is important
to make an accurate diagnosis are not usually seen until the fourth or fifth
day. The suddenness of the onset, the greater frequency of the chill, and the
RELAPSING FEVER. 109
early prostration are the distinctive features in typhus. The brain symptoms
too are earlier. It is easy to put down on paper elaborate differential distinc-
tions, which are practically useless at the bedside. The Widal reaction and
blood cultures are important aids, but in sporadic cases the diagnosis is some-
times extremely difficult. I have seen Murehison himself in doubt, and more
than once I have known the diagnosis to be deferred until the sectio cadaveris.
Severe cerebro-spinal fever may closely simulate typhus at the outset, but the
diagnosis is usually clear within a few days. Malignant variola also has cer-
tain features in common with severe typhus, but the greater extent of the
haemorrhages and the bleeding from the mucous membranes make the diagnosis
clear within a short time. The rash at first resembles that of measles, but in
the latter the eruption is brighter red in color, often crescentic or irregular in
arrangement, and appears first on the face.
The frequency with which other diseases are mistaken for typhus is shown
by the fact that during and following the epidemic of 1881 in New York 108
cases were wrongly diagnosed — one-eighth of the entire number — and sent to
the Eiverside Hospital (F. W. Chapin).
Treatment. — The general management of the disease is like that of
typhoid fever. Hydrotherapy should be thoroughly and systematically em-
ployed. Judging from the good results which we have obtained by this
method in typhoid cases with nervous symptoms much may be expected
from it. Certain authorities have spoken against it, but it should be given
a more extended trial. Medicinal antipyretics are even less suitable than in
typhoid, as the tendency to heart-weakness is often more pronounced. As
a rule, the patients require from the outset a supporting treatment; water
should be freely given^ and alcohol in suitable doses, according to the condi-
tion of the pulse.
The bowels may be kept open by mild aperients. The so-called specific
medication, by sulphocarbolates, the sulphides, carbolic acid, etc., is not
commended by those who have had the largest experience. The special nerv-
ous symptoms and the pulmonary symptoms should be dealt with as in typhoid
fever. In epidemics, when the conditions of the climate are suitable, the
cases are best treated in tents in the open air.
III. RELAPSING FEVER (Febris recurrens).
Definition. — A specific infectious disease caused by the spirochaete (spi-
rillum) of Obermeier, characterized by a definite febrile paroxysm which usu-
ally lasts six days and is followed by a remission of about the same length
of time, then by a second paroxysm, which may be repeated three or even
four times, whence the name relapsing fever.
Etiology. — This disease, which has also the names " famine fever " and
*' seven-day fever," has been known since the early part of the eighteenth
century, and has from time to time extensively prevailed in Europe, espe-
cially in Ireland. It is common in India, where the conditions for its devel-
opment seem always to be present, and where it was specially studied by
Vandyke Carter, of Bombay. It appeared in the United States in 1844,
when cases were admitted to the Philadelphia Hospital, which are described
110 SPECIFIC INFECTIOUS DISEASES.
by Meredith Clymer in his work on Fevers. Flint saw cases in 1850-51. In
1869 it prevailed extensively in epidemic form in New York and Philadel-
phia; since when it has not reappeared. Only an occasional case has occurred
in England and Wales during the past twenty years. In the Philippines there
have been several severe outbreaks.
The special conditions under which it occurs are similar to those of
typhus fever. Overcrowding and deficient food are the conditions which
seem to promote the rapid spread of the virus. Neither age, sex, nor season
seems to have any special influence. It is a contagious disease and may
be communicated from person to person, but is not so contagious as typhus.
Murchison thinks it may be transported by fomites. One attack does not
confer immunity from subsequent attacks. In 1873 Obermeier described an
organism in the blood which is now recognized as the specific agent. This
spirillum, or more correctly spirochete, is from 3 to 6 times the length of
the diameter of a red blood-corpuscle, and forms a narrow spiral filament
which is readily seen moving among the red corpuscles during a paroxysm.
They are present in the blood only during the fever. Shortly before the
crisis and in the intervals they are not found, though small glistening bodies,
which are stated to be their spores, appear in the blood. The disease has
been produced in human beings by inoculation with blood taken during the
paroxysm. It has also been produced in monkeys. Bed-bugs may suck out
the spirilla, and Tictin reproduced the disease by injecting into a healthy
monkey blood sucked by a bug from an infected monkey. Nothing is yet
known with reference to the life history of the spirochgete. It has not been
found in the secretions or excretions.
Morbid Anatomy. — There are no characteristic anatomical appearances
in relapsing fever. If death takes place during the paroxysm th,e spleen is
large and soft, and the liver, kidneys, and heart show cloudy swelling. There
may be infarcts in the kidneys and spleen. The bone-marrow has been found
in a condition of h3-perplasia. Ecchymoses are not uncommon.
Symptoms. — The incubation appears to be short, and in some instances
the attack occurs promptly after exposure; more frequently, however, from
five to seven days elapse.
The invasion is abrupt, with chill, fever, and intense pain in the back
and limbs. In young persons there may be nausea, vomiting, and convul-
sions. The temperature rises rapidly and may reach 104° on the evening
of the first da3\ Sweats are common. The pulse is rapid, ranging from
110 to 130. There may be delirium if the fever is high. Swelling of the
spleen can be detected early. Jaundice is common in some epidemics. The
gastric symptoms may be severe. There are seldom intestinal s}Tnptoms.
Cough may be present. Occasionally herpes is noted, and there may be
miliary vesicles and petechias. During the paroxysm the blood invariably
shows the spirochgete, and there is usually a leucoc}i;osis (Ouskow). After
the fever has persisted with severity or even with an increasing intensity
for five or six days the crisis occurs. In the course of a few hours, accom-
panied by profuse sweating, sometimes by diarrhoea, the temperature falls
to normal or even subnormal, and the period of apyrexia begins.
The crisis may occur as early as the third day, or it may be delayed to
the tenth; it usually comes, however, about the end of the first week. In
RELAPSING FEVER.
Ill
delicate and elderly persons there may be collapse. The convalescence is
rapid, and in a few days the patient is up and abont. Then in a week,
usually on the fourteenth day, he again has a rigor, or a series of chills;
the fever returns and the attack is repeated. A second crisis occurs from
the twentieth to the twenty-third day, and again the patient recovers rap-
idly. As a rule, the relapse is shorter than the original attack. A second
and a third may occur, and there are instances on record of even a fourth
and a fifth. In epidemics there are cases which terminate by crisis on the
seventh or eighth day without the occurrence of relapse. In protracted cases
the convalescence is very tedious, as the patient is much exhausted.
Eelapsing fever is not a very fatal disease. Murchison states that the
mortality is about 4 per cent. In the enfeebled and old, death may occur
at the height of the first paroxysm.
Complications are not frequent. In some epidemics hsematemesis and
hsematuria have occurred. Pneumonia is not infrequent. The acute enlarge-
ment of the spleen may end in rupture. Post-febrile paralyses may occur.
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 IB 17 1R 19 20 51 9'J 23 94
RIsSiiSilSBBSSSSHBBBSSifflSafiSBB
'/■■■MSSBBBSSSBBBSSBnHHMHHiBinBSI
IHWWVHI'
■■BBSBmBBBSSmJBBBSBBBSbkiBBBSSBSBSBmiiwBBBSBSS
■awBBSB,SSSByMyAMBigkw^MWi?giJiraMww ■■■■■■■■!■■■■ ■'ATJgw^
107.6°
105.8°
104.0°
102.2°
100.4°
98.6°
96.8°
95.0"
Chart VI.— Relapsing Fever (Murchison).
Ophthalmia has followed in certain epidemics, and may prove a very tedious
and serious complication. Jaundice has already been mentioned. In pregnant
women abortion usually takes places. Convulsions occasionally follow. But-
ton, the well-known worker on tropical diseases, died in status epilepticus
some weeks after the attack.
Diag:nosis. — The onset and general symptoms may not at first be dis-
tinctive. At the beginning of an epidemic the cases are usually regarded as
anomalous typhoid; but once the typical course is followed in a case the
diagnosis is clear. The blood examination is distinctive.
Treatment. — The paroxysm can neither be cut short nor can its recur-
rence be prevented. It might be thought that quinine, with its powerful
action, would certainly meet the indications, but it does not seem to have the
slightest influence. The disease must be treated like any other continued
fever, by careful nursing, a regular diet, and ordinary hygienic measures.
Of special symptoms, pain in the back and in the limbs and joints demand
112 SPECIFIC INFECTIOUS DISEASES.
opium. In enfeebled persons the collapse at the crisis may be serious, and
stimulants with ammonia and digitalis should be given freely.
IV. SMALL-POX (Variola).
Definition. — An acute infectious disease characterized by a cutaneous
eruption which passes through the stages of papule, vesicle, pustule, and
crust. ^
History. — The disease existed in China many centuries before Christ. 1
The pesta magna described by Galen (of which Marcus Aurelius died) is
believed to have been small-pox. In the sixth century it prevailed, and sub-
sequently, at the time of the Crusades, became wide-spread. It was brought
to America by the Spaniards early in the sixteenth century. The first accu-
rate account was given by Ehazes, an Arabian physician who lived in the
ninth century, and whose admirable description is available in Greenhill's
translation for the Sydenham Society. In the seventeenth century the illus-
trious Sydenham differentiated measles from small-pox. Special events in
the history of the disease are the introduction of inoculation into Europe,
by Lady Mary Wortley Montagu, in 1718, and the discovery of vaccination
by Jenner, in 1796. I
Etiology. — Small-pox is one of the most virulent of contagious diseases,
and persons exposed, if unprotected by vaccination, are almost invariably
attacked. Instances of natural immunity are rare. It is said that Diemer-
broeck, a celebrated Utrecht professor in the seventeenth century, was not
only himself exempt, but likewise many members of his family. One of
the nurses in the small-pox department of the Montreal General Hospital
stated that she had never been successfully vaccinated, and she certainly
had no mark. An attack may not protect for life. There are undoubted
cases of a second, reputed instances, indeed, of a third attack.
Age. — Small-pox is common at all ages, but is particularly fatal to young
children. Of 3,164 deaths in the Montreal epidemic of 1885-'86, 2,717 were
of children under ten years of age. The foetus in utero may be attacked, but
only if the mother herself is the subject of the disease. The child may be
born with the rash out or with the scars. In the case of twins, only one
may be attacked; Kaltenbach records an instance of triplets, only two of
which were affected (Comby). Children born in a small-pox hospital, if
vaccinated immediately, may escape the disease; usually, however, they die ,
early. (See Hunter's works, iv, p. 74.) I
Sex. — Males and females are equally affected.
Race. — Among aboriginal races small-pox is terribly fatal. When the
disease was first introduced into America the Mexicans died by thousands,
and the North American Indians have also been frequently decimated by
this plague. It is stated that the negro is especially susceptible, and the
mortality is greater — about 43 per cent in the black, against 39 per cent in
the white (W. M. Welch).
It is claimed that isolation hospitals increase the incidence of the disease
in a locality. J. Glaister, who has considered the whole question very care-
fully, concludes that as a centre of traffic such an. institution, through the
channels of unavoidable human intercourse, naturally favors the spread of
i
SMALL-POX. 113
ihe disease locally, but decides against the aerial conveyance of the disease,
in spite of the very strong evidence (mentioned in the last edition in the
case of the hospital ship on the Thames).
The disease smoulders here and there in different localities, and when
conditions are favorable becomes epidemic. This was well illustrated by the
celebrated Montreal outbreak of 1885. For several years there had been no
small-pox in the city, and a large unprotected population grew up among
the French-Canadians, many of whom were opposed to vaccination. On
February 28, a Pullman-ear conductor, who had travelled from Chicago,
where the disease had been slightly prevalent, was admitted into the Hotel-
Dieu, the civic small-pox hospital being at the time closed. Isolation was
not carried out, and on the 1st of April a servant in the hospital died of
small-pox. Following her decease, with a negligence absolutely criminal, the
authorities of the hospital dismissed all patients presenting no symptoms of
contagion, who could go home. The disease spread like fire in dry grass,
and within nine months there died in the city o'f small-pox 3,164 persons.
Variations in the Virulence of Epidemics. — Sydenham states that
" small-pox also has its peculiar kinds, which take one form during one series
of years, and another during another " ; and not only does what he called
the epidemic constitution vary greatly, but one sometimes sees the most
extraordinary variations in the intensity of the disease in members of a fam-
ily all exposed to the same infection, A striking illustration of this variabil-
ity has been given in the recent epidemics, which have been of so mild a
character that in many localities it has been mistaken for chicken-pox; in
others, particularly in the United States, the belief prevailed that a new
disease had arisen, to which the name " Cuban itch " or " Philippine itch "
has been given. Very often a correct diagnosis has not been reached until
a fatal case has occurred. As will be mentioned, a small outbreak occurred
in one of my wards for colored patients, which we mistook at first for
chicken-pox. The same peculiarities have been observed in the Leicester,
N"ottingham, and Cambridge outbreaks. Even in unvaccinated children the
disease has been exceedingly mild. Some of the Leicester cases had only
a few pocks (Allan Warner) ; but this is an old story in the history of the
disease. John Mason Good, in commenting on this very point, refers to the'
great variability in the epidemics, and states that he himself as a child of
six (1770) passed through small-pox with "scarcely any disturbance and
not more than twenty scattered pustules " !
Recent Prevalence. — In the United States, according to Dr. Wyman's
last report for the fiscal year 1904, there had been a steady decrease. The
figures for 1903 were 43,590 cases and 1,643 deaths; for 1904, 35,106 cases
and 1,118 deaths. In England and Wales there were 760 deaths in 1903,
a rate of 33 per million living ; the rates in the previous four years having
been 5, 3, 7, and 75 severally (John W. Tatham).
Nature of Contagion. — Protozoon-like bodies were first described in the
'skin lesions by Guarnieri — the cytoryctes variolce. Cou.ncilman and his col-
leagues describe a protozoon with a double cycle and cytoplasmic stage, with
small structureless bodies in the lower layer of the epithelial cells. Increas-
ing in size, they become reticulated and segment into small rounded bodies.
In the intranuclear stage these small round bodies or granules invade the
9
114 SPECIFIC INFECTIOUS DISEASES.
nuclei of the epithelial cells, increase in size, and form a series of vacuoles
around a central vacuole. Calkins, an acknowledged expert in the protozoa,
has confirmed the main facts in the life history of this organism. Howard
and Perkins, of Cleveland, describe identical changes. So definite is the
relation of the parasites to the skin lesions that it seems highly probable they
may be the cause of the disease. The dried scales constitute by far the
most important element, and as a dust-like powder are distributed ever}'^-
where in the room during convalescence, becoming attached to clothing and
various articles of furniture. The disease is probably contagious from a very
early stage, though I think it has not yet been determined whether the con-
tagion is active before the eruption develops. The poison is of unusual
tenacity and clings to infected localities. It is conveyed by persons who have
been in contact with the sick and by fomites. During epidemics it is no doubt
widely spread in street-cars and public conveyances. It must not be forgotten
that an unprotected person may contract a very virulent form of the disease
from the mild varioloid.
Morbid Anatomy. — The pustules may be seen upon the tongue and the
buccal mucosa, and on the palate; sometimes also in the pharjmx and the
upper part of the oesophagus. In exceptionally rare cases the rash extends
down the oesophagus and even into the stomach. Swelling of the Peyer's
follicles is not uncommon; the pustules have been seen in the rectum.
In the larynx the eruption may be associated with a fibrinous exudate and
sometimes with oedema. Occasionally the inflammation penetrates deeply
and involves the cartilages. In the trachea and bronchi there may be ulcera-
tive erosions, but true pocks, such as are seen on the skin, do not occur.
The heart occasionally shows myocardial changes, parenchymatous and
fatty; endocarditis and pericarditis are uncommon. French writers have
described an endarteritis of the coronary vessels in connection with small-
pox. The spleen is markedly enlarged. Apart from the cloudy swelling and
areas of coagulation-necrosis, lesions of the kidneys are not common. jSTephri-
tis -may occur during convalescence.
In the hsemorrhagic form extravasations are found on the serous and
mucous surfaces, in the parenchyma of organs, in the connective tissues,
and about the nerve-sheaths. In one instance I found the entire retro-
peritoneal tissue infiltrated with a large coagulum, and there were also
extensive extravasations in the course of the thoracic aorta. Haemorrhages
in the bone-marrow have also been described by Golgi. There may be heem-
orrhages into the muscles. Ponfick has described the spleen as very firm
and hard in hsemorrhagic small-pox, and such was the case in seven instances
I examined. In these rapidly fatal forms the liver has been described as fatty,
but in 5 of my 7 cases it was of normal size, dense, and firm.
The following description of the finer changes is taken largely from the
recent exhaustive study by Councilman, McGrath, and Brinkerhoff (1904).
The specific lesion is " a focal degeneration of the stratified epithelium, vacu-
olar in character, and accompanied by serous exudation and the formation
of a reticulum." The specific lesions are limited to the skin, the mucous
membranes of the soft palate, the phar}Tix, and the oesophagus. The factors
in the formation of the pustule are degeneration of the epithelial cells, asso-
ciated with fluid and cellular exudate. The cells of the lower layers of the
SMALL-POX. 115
epidermis are first involved. They become swollen, the nuclei are shrunken
and formless, the exudate increases in amount, enlarging the spaces of the
reticulum, and the cells represent the different varieties of leucocytes, poly-
nuclear neutrophiles being most numerous. The umbilication and central
depression usually correspond, as Weigert suggests, to the area of primary
necrosis. The hair follicle and the sweat gland may play some part. The para-
sites described occur chiefly in the cells of the rete ■ mueosum. Associated
lesions are numerous, particularly proliferation in the haematopoietic organs.
Cellular infiltrations occur constantly in the testicle, usually in the kidney,
the liver, and the adrenal glands. The anaemic focal necroses in the testicles
seem almost specific in the disease, and in the bone-marrow there are foci of
necrosis and of hemorrhage with hyperplasia of the myelocytes, and a marked
reduction or even complete absence of the polynuclear leucocytes. This was
the change described originally by Chiari as osteomyelitis variolosa. Asso-
ciated bacterial lesions are common, due to the pyogenic bacteria which are
always present in severe cases.
Symptoms. — Three forms of small-pox are described:
1. Variola vera; (a) Discrete, (&) Confluent.
2. Variola licemorrliagica ; (a) Purpura variolosa or black small-pox;
(h) Hsemorrhagic pustular form, variola hsemorrhagica pustulosa.
3. Varioloid, or small-pox modified by vaccination.
1. Vaeiola Vera. — The affection may be conveniently described under
various stages : Incubation. — " From nine to fifteen days ; oftenest twelve."
I have seen it as early as the eighth day after exposure, and there are well-
authenticated instances in which this stage has been prolonged to twenty days.
It is unusual for patients to complain of any symptoms.
Invasion. — In adults a chill and in children a convulsion are common
initial symptoms. There may be repeated chills within the first twenty-
four hours. Intense frontal headache, severe lumbar pains, and vomiting
are very constant features. The pains in the back and in the limbs are more
severe in the initial stage of this than of any other eruptive fever, and their
combination with headache and vomiting is so suggestive that precautionary
measures may often be taken several days before the eruption appears. The
temperature rises quickly, and may on the first day be 103° or 104°. The
pulse is rapid and full, not often dicrotic. In severe cases there may be
marked delirium, particularly if the fever is high. The patient is restless
and distressed, the face is flushed, and the eyes are bright and clear. The
skin is usually dry, though occasionally there are profuse sweats. One
can not Judge from the initial symptoms whether a case is likely to be dis-
crete or confluent, as convulsions, severe backache, and high fever may pre-
cede a very mild attack.
Initial Rashes. — Two forms can be distinguished: the diffuse, scarlatinal,
and the macular or measly form; either of which may be associated with
petechise and occupy a variable extent of surface. In some instances they are
general, but as a rule, as pointed out by Simon, they are limited either to
the lower abdominal areas, to the inner surfaces of the thighs, and to the lat-
eral thoracic region, or to the axillse. Occasionally they are found over the
extensor surfaces, particularly in the neighborhood of the knees and elbows.
These rashes, usually purpuric, are often associated with an erythematous
116
SPECIFIC INFECTIOUS DISEASES.
or er^'sipelatous blush. The scarlatinal rash may come out as early as the
second day, and be as diffuse and vivid as in a true scarlatina. The measly
rash may also be diffuse and resemble closely that of measles. Urticaria
2 3 4 5 6 7
10 11 12 13 14 15 16 ir 18
104° F.-40.0°
102.2° F.— 39.0°
100.4° F.— 38.0"
i.6° F.— 37.0=
■■■■■■■■■■■■■■■■■■■■■■■'
■iiuiiiiiilldli
HHiiiiiiiiim
IM—W liiBHMI
Initial Fever Eruption.
Suppurative Fever.
Chart YII, — True Small-pox (Striimpell).
is only occasionally seen. It was present once in my Montreal cases. The
initial rashes are more abundant in some epidemics than in others. They
occur in from 10 to 16 per cent of cases.
Eruption. — (1) In the discrete form, usually on the fourth day, mac-
ules appear on the forehead, preceded sometimes by an erythematous flush,
and on the anterior surfaces of the wrists. Within the first twenty-four
hours from their appearance they occur on other parts of the face and on the
extremities, and a few are seen on the trunk. The spots are from 3—3
millimetres in diameter, of a bright red color, and disappear completely
on pressure. As the rash comes out the temperature falls, the general
s}Tnptoms subside, and the patient feels comfortable. On the fifth or sixth
day the papules change into vesicles with clear summits. Each one is ele-
vated, circular, and presents a little depression or umbilication in the
centre. About the eighth day the vesicles change into pustules, the umbil-
ication disappears, the flat top assumes a globular form and becomes grayish-
yellow in color, owing to the contained pus. There is an areola of injec-
tion about the pustules and the skin between them is swollen. This
maturation first takes place on the face, and follows the order of the appear-
ance of the eruption. The temperature now rises — secondary fever — and the
general symptoms return. The swelling about the pustules is attended with
a good deal of tension and pain in the face; the eyelids become swollen and
closed. In the discrete form the temperature of maturation does not usually
remain high for more than twenty-four or twentj^-six hours, so that on the
tenth or eleventh day the fever disappears and the stage of convalescence
begins. The pustules rapidly dry, first on the face and then on the other
parts, and by the fourteenth or fifteenth day desquamation may be far
advanced on the face. The march and distribution of the rash are often most
characteristic. The abdomen and groins and the legs are the parts least
affected. The rash is often copious on the upper part of the back, scanty' on
the lower. Vesicles in the mouth, phar^-nx, and larynx, cause soreness and
SMALL-POX. 117
swelling in these parts, with loss of voice. Whether pitting takes place de-
pends a good deal upon the severity of, the disease. In a majority of cases
Sydenham's statement holds good, that " it is very rarely the case that the
distinct small-pox leaves its mark." The odor of a small-pox patient is very
distinctive even in the early stages, and I have known it to be a help in the
diagnosis of a doubtful case.
(3) The Confluent Form. — With the same initial symptoms, though usu-
ally of greater severity, the rash appears on the fourth, or, according to
Sydenham, on the third day. The more the eruption shows itself before the
fourth day, the more sure it is to become confluent (Sydenham). The pap-
ules at first may be isolated, and it is only later in the stage of maturation
that the eruption is confluent. But in severer cases the skin is swollen and
hyperaemic and the papules are very close together. On the feet and hands,
too, the papules are thickly set; more scattered on the limbs; and quite dis-
crete on the trunk. With the appearance of the eruption the symptoms sub-
side and the fever remits, but not to the same extent as in the discrete form.
Occasionally the temperature falls to normal and the patient may be very
comfortable. Then, usually on the eighth day, the fever again rises, the
vesicles change to pustules, the hypersemia becomes intense, the swelling of
the face and hands increases, and by the tenth day the pustules have fully
maturated, many of them have coalesced, and the entire skin of the head and
extremities is a superficial abscess. The fever rises to 103° or 105°, the pulse
is, from 110 to 120, and there is often delirium. As pointed out by Syden-
ham, salivation in adults and diarrhoea in children are common symptoms
of this stage. There is usually much thirst. The eruption may also be pres-
ent in the mouth, and usually the pharynx and larynx are involved and the
voice is husky. Great swelling of the cervical lymphatic glands occurs. At
this stage the patient presents a terrible picture, unequalled in any other
disease; one which fully justifies the horror and fright with, which small-pox
is associated in the public mind. Even when the rash is confluent "on the
face, hands, and feet, the pustules remain discrete on the trunk. The danger,
as pointed out by Sydenham, is in proportion to the number upon the face.
" If upon the face they are as thick as sand, it is no advantage to have them
few and far between on the rest of the body." In fatal cases, by the tenth
or eleventh day the pulse gets feebler and more rapid, the delirium is marked,
there is subsultus, sometimes diarrhoea, and with these symptoms the patient
dies. In other instances between the eighth and eleventh day hsemorrhagic
features occur. When recovery takes place, the patient enters on the eleventh
or twelfth day the period of desiccation.
Desiccation. — The pustules break and the pus exudes or they dry
and form crusts. Throughout the third week the desiccation proceeds and
in cases of moderate severity the secondary fever subsides; but in others it
may persist until the fourth week. The crusts in confluent small-pox adhere
for a long time and the process of scarring may take three or four weeks.
On the face they fall off singly, but the tough epidermis of the hands and
feet may be shed entire.
2. HEMORRHAGIC SMALL-POX occurs in two forms. In one, the petechial
or black small-pox — purpura variolosa — the special symptoms appear early
and death follows in from two to six days. In the other form the case pro-
118 SPECIFIC IXFECTIOUS DISEASES.
gresses as one of ordinary variola, and in the resicular or pustular stage
hsemorrliages take place into the pocks or from the mucous membranes —
variola liCEmorrhagica pustulosa.
Yariola haemorrhagica is more common in some epidemics than in others.
It is less frequent in children than in adults. Of 27 cases admitted to the
small-pos department of the Montreal General Hospital there vrere 3 under
ten years, -1 between fifteen and twenty, 9 between twenty and twenty-five,
7 between twent3'-five and thirty-five, 3 between thirty-five and fortj^-five, and
1 above fifty. Young and vigorous persons seem more liable to this form.
Several of my cases were above the average in muscular development. Men
are more frequently affected than women; thus in my list there were 21 males
and only 6 females. The influence of vaccination is shown in the fact that
of the eases 14 were un vaccinated, while not one of the 13 who had scars had
been revaccinated.
In purpura variolosa the illness starts with the usual s3'mptoms, but with
more intense constitutional disturbance. On the evening of the second or on
the third day there is a diffuse hypersemic rash, particularly in the groins,
with small punctiform hsemorrliages. The rash extends, becomes more dis-
tinctly ha?morrhagic, and the spots increase in size. Ecchymoses appear on
the conjunctiva, and as early as the third day there may be hsemorrliages
from the mucous membranes. Death may take place before the papules
appear. In this truly terrible affection the patient may present a frightful
appearance. The skin may have a uniformly purplish hue and the unfortu-
nate victim may even look plum-colored. The face is swollen and large con-
junctival haemorrhages ^vith the deeply sunken comeae gives a ghastly appear-
ance to the features. The mind may remain clear to the end. Death occurs
from the third to the sixth day; thus in thirteen of my cases it took place
between these dates. The earliest death was on the third day and there were
no traces of papules. There may be no mucous haemorrhages; thus in one
case of a most virulent character death occurred without bleeding early on
the fourth day. Hsematuria is perhaps most common, next haematemesis, and
melsena was noticed in a third of the cases. Metrorrhagia was present in one
only of the six females on my list. Haemoptysis occurred in five cases. The
pulse in this form of small-pox is rapid and often hard and small. The
respirations are greatly increased in frequency and out of all proportion to
the intensity of the fever.
In variola pustulosa li(Binorrliagica the disease progresses as a severe case,
and the hsemorrhages do not occur until the vesicular or pustular stage. The
first indication is haemorrhage into the areolse of the pocks, and later the matu-
rated pustules fill with blood. The earlier the hemorrhage the greater is the
danger. Bleeding from the mucous membranes is also common in this form,
and the great majority of the cases prove fatal, usually on the seventh, eighth,
or ninth day, but a few cases recover. In patients with the discrete form, if
allowed to get up early, haemorrhage may take place into the pocks on the legs.
Leucocyte Reaction. — In variola vera there is a marked leucocytosis, 12-
16 thousand, about the eighth day, then a slight decline and a rise again
about the twelfth or fourteenth day, sometimes to 18,000 or 20,000. There
is an increase in the mononuclear elements, which may be the only marked
feature of the mild cases (Magrath, Brinkerhoff, and Bancroft).
SMALL-POX. 119
3. Varioloid. — This term is applied to the modified form which affects
persons who have been vaccinated. It may set in with abruptness and sever-
ity, the temperature reaching 103°. More commonly it is in every respect
milder in its initial symptoms, though the headache and backache may be
very distressing. The papules appear on the evening of the third or on the
fourth day. They are few in number and may be confined to the face and
hands. The fever drops at once and the patient feels perfectly comfortable.
The vesiculation and maturation of the pocks take place rapidly, and there
is no secondary fever. There is rarely any scarring. As a rule, when small--
pox attacks a person who has been vaccinated within five or six years the
disease is mild, but it may prove severe, even fatal.
Abortive Types. — As already mentioned, recent epidemics have been char-
acterized by the large number of mild cases. Even in unvaccinated children,
only a few pustules may appear, and the disease is over in a few days. Even
with a thickly set eruption the vesicles at the fifth or sixth day, instead of fill-
ing, dry and abort, forming the so-called horn-, crystalline-, or wart-pox. Vari-
ola sine eruptione is described. I saw no cases of the kind in Montreal. They
seem to have been not uncommon in the recent epidemics. Bancroft observed
twelve cases in the Boston outbreak, all among physicians and attendants.
The symptoms are headache, pain in the back, fever, and vomiting. As already
mentioned, the- pocks may be very scanty and easily overlooked, even in unvac-
cinated persons. One of Bancroft's cases was of special interest — a pregnant
woman who had slight symptoms after exposure, but no rash. Her child
showed a typical eruption when two days old.
Complications. — Considering the severity of many of the cases and the
general character of the disease, associated with multiple foci of suppuration,
the complications in small-pox are remarkably few.
Laryngitis is serious in three ways : it may produce a fatal oedema of the
glottis; it is liable to extend and involve the cartilages, producing necrosis;
and by diminishing the sensibility of the larynx, it may allow irritating par-
ticles to reach the lower air-passages, where they excite bronchitis or broncho-
pneumonia.
Broncho-pneumonia is almost invariably present in fatal cases. Lobar pneu-
monia is rare. Pleurisy is common in some epidemics.
The cardiac complications are also rare. In the height of the fever a
systolic murmur at the apex is not uncommon; but endocarditis, either simple
or malignant, is rarely met with. Pericarditis, too, is very uncommon. Myo-
carditis seems to be more frequent, and may be associated with endarteritis of
the coronary vessels.
Of complications in the digestive system, parotitis is rare. In severe cases
there is extensive pseudo-diphtheritic angina. Vomiting, which is so marked
a symptom in the early stage, is rarely persistent. Diarrhoea is not uncom-
mon, as noted by Sydenham, and is very constantly present in children.
Albuminuria is frequent, but true nephritis is rare. Inflammation of the
testes and of the ovaries may occur.
Among the most interesting and serious complications are those pertaining
to the nervous system. In children convulsions are common. In adults the
delirium of the early stage may persist and become violent, and finally sub-
side into a fatal coma. Post-febrile insanity is occasionally met with during
120 SPECIFIC INFECTIOUS DISEASES.
convalescence, and very rarely epilepsy. Many of the old writers spoke of
paraplegia in connection with the intense backache of the early stage, but it is
probably associated with the severe agonizing lumbar and crural pains and is
not a true paraplegia. It must be distinguished from the form occurring in
convalescence, which may be due to peripheral neuritis or to a diffuse myelitis
(Westphal). The neuritis may, as in diphtheria, involve the phar}Tix alone,
or it may be multiple. Of this nature, in all probability, is the so-called pseudo-
tabes, or ataxie variolique. Hemiplegia and aphasia have been met with in a
few instances, the result of encephalitis.
Among the most constant and troublesome complications of small-pox are
those involving the skin. During convalescence boils are very frequent and
may be severe. Acne and ecthyma are also met with. Local gangrene in
various parts may occur.
Arthritis may occur, usually in the period of desquamation, and may pass
on to suppuration. Acute necrosis of the bone is sometimes met with.
A remarkable secondary eruption (recurrent small-pox) occasionally occurs
after desquamation.
Special Senses. — The eye affections which were formerly so common and
serious are not now so frequent, owing to the care which is given to keeping
the conjunctivEe clean. A catarrhal and purulent conjunctivitis is common in
severe cases. The secretions cause adhesions of the eyelids, and unless great
care is taken a diffuse keratitis is excited, which may go on to ulceration and
perforation. Iritis is not very uncommon. Otitis media is an occasional com-
plication, and usually results from an extension of the disease through the
Eustachian tubes.
Prognosis. — In unprotected persons small-pox is a ver}^ fatal disease, the
death-rate ranging from 25 to 35 per cent. In William M. Welch's report from
the Municipal Hospital, Philadelphia, of 2,831 eases of variola, 1,534 — i. e.,
54.18 per cent — died, while of 2,169 cases of varioloid only 28 — i. e., 1.29 per
cent — died. Purpura variolosa is invariably fatal, and a majority of those
attacked with the severer confluent forms die. The intemperate and debilitated
succumb more readilj' to the disease. As Sydenham observed, the danger is
directly proportionate to the intensity of the disease on the face and hands.
"When the fever increases after the appearance of the pustules, it is a bad
sign; but if it is lessened on their appearance, that is a good sign" (Ehazes).
Very high fever, with delirium and subsultus, are symptoms of ill omen. The
disease is particularly fatal in pregnant women and abortion usually takes
place. It is not, however, uniformly so, and I have twice known severe cases
to recover after miscarriage. Moreover, abortion is not inevitable. Very severe
phar3mgitis and larjugitis are fatal complications.
Death results in the early stage from the action of the poison upon the
nervous system. In the later stages it usually occurs about the eleventh or
twelfth day, at the height of the eruption. In children, and occasionally in
adults, the lar^Tigeal and pulmonary complications prove fatal.
Diagnosis. — During an epidemic the initial chill, the headache and back-
ache, and the vomiting at once put the physician on his guard.
The initial rashes may lead to error. The scarlatinal rash has rarely the
extent and never the persistence of the rash in true scarlet fever. I have known
the rash of measles to be mistaken for the initial rash of small-pox. The gen-
SMALL-POX. 121
eral condition of the patient, and the presence of coryza and conjunctivitis and
Koplik's sign, may be better guides than the rash itself.
Malignant hgemorrhagic small-pox may prove fatal before the characteristic
rash appears. Of 27 cases of hgemorrhagic small-pox, in only one, in which
death occurred on the third day, did inspection fail to show the papules. I^n
3 cases dying on the fourth day the characteristic papular rash was noticed.
It may be difficult or impossible to recognize this form of hgemorrhagic small-
pox from hcEmorrhagic scarlet fever or JicBmorrhagic measles, though in the
latter there is rarely so constant involvement of the mucous membranes. Natu-
rally enough, as they are allied affections, varicella is the disease which most
frequently leads to error. Particularly has this been the case in the mild
epidemic which has prevailed throughout the country during the past three
years. A negro patient was admitted to my wards on the fourth day of the
disease. Small-pox was not prevalent at the time, and the case was regarded
as one of varicella. Subsequently eight eases appeared, several of exceeding
mildness, but our mistake was forcibly brought home to us by the occurrence,
in a man who had been exposed in the ward, of a case of confluent small-pox
of great severity. The following points are to be borne in mind: first, the
experience of the past few years has shown that very mild epidemics of true
small-pox may occur ; secondly, any large number of cases of a contagious dis-
ease with a pustular eruption occurring in adults is strongly in favor of small-
pox. The characters of the rash are of less value. Its abundance on the trunk
in varicella is important. At the outset the papules have rarely the shotty,
hard feel of small-pox. The vesicles are more superficial, the infiltrated areola
is not so intense nor so constant, and as a rule the pocks may be seen in the
same patient in all stages of development. The longer period of invasion, the
prodromal rashes, the greater intensity of the onset, are also important points
in small-pox. But, as I have said, there are mild epidemics in which it must
be confessed that the recognition of the nature of the outbreak is sometimes
only confirmed by the appearance of a severe case of the confluent or of the
hgemorrhagic form.
The disease may be mistaken for cerehro-spinal fever, in which purpuric
symptoms are not uncommon. A four-year-old child was taken suddenly ill
with fever, pains in the back and head, and on the second or third day petechige
appeared on the skin. There were retraction of the head, and marked rigidity
of the limbs. The hgemorrhages became more abundant; and finally hgema-
temesis occurred and the child died on the sixth day. At the post mortem
there were no lesions of cerebro-spinal fever, and in the deeply hemor-
rhagic skin the papules could be readily seen. The post-mortem diagnosis
of small-pox was unhappily confirmed by the mother taking the disease and
dying of it.
Pustular Sypliilides. — A very copious pustular rash in syphilis may resem-
ble variola, particularly if accompanied by fever, but the history and the dis-
tribution, particularly the slight amount on the face, leaves no question as to
the diagnosis.
Pustular glanders has been mistaken for small-pox. In a remarkable in-
stance of the kind in Montreal there was a wide-spread pustular eruption,
which we thought at first was small-pox, but the subsequent course and the
fact that there was glanders among the horses in the stable led to the correct
10
122 SPECIFIC INFECTIOUS DISEASES.
diagnosis. TPie eruption resembled exactly that described in Bayer's mono-
graph (De la Morve, 1837).
Impetigo contagiosa is stated to have been mistaken for variola.
Treatment. — General Considerations. — Segregation in special hospitals
is imperative. In the case of local outbreaks temporary barracks or tents may
be constructed. In the larger cities^ considering the frequency with which
epidemics recur, it is worth while to have a special small-pox hospital.
If the grounds are ample and all necessary precautions taken, there is
no reason why this should not be part of the general hospital for infectious
diseases.
The criticism, already referred to, of the danger of aerial conveyance in
small-pox is, I think, correct.
In the early stages two symptoms call for treatment : the pain in the back,
which requires opium in some form, as advised by Sydenham; and the vomit-
ing, which is very difficult to check and may be uncontrollable. No food should
be given except a little ice and champagne, and it usually stops with the
appearance of the eruption.
The diet is that usually given in fevers, with plenty of cold water, or barley
water or the Scotch borse — oatmeal and water, to which lemon-juice may be
added.
For the fever, cold sponging or the cold bath may be used; when there is
much delirium with high fever the latter is preferable, or the cold pack.
The treatment of the eruption is important. After trying all sorts of
remedies, such as puncturing the pustules with nitrate of silver, or treating
them with iodine and various ointments, I came to Sydenham's conclusion that
in guarding the face against being disfigured by the sears " the only effect of
oils, liniments, and the like, was to make the white scurfs slower in coming
off." The constant application on the face and hands of lint soaked in cold
water, to which antiseptics such as carbolic acid or bichloride may be added,
is perhaps the most suitable local treatment. It is very pleasant to the patient,
and for the face it is well to make a mask of lint, which can then be covered
with oiled silk. When the crusts begin to form, the chief point is to keep them
thoroughly moist, which may be done with oil or glycerin. This prevents the
desiccation and diffusion of the flakes of epidermis. Vaseline is particularly
useful, and at this stage may be freely used upon the face. It also relieves the
itching. For the odor, which is sometimes so characteristic and disagreeable,
the dilute carbolic solutions are probably best. If the eruption is abundant on
the scalp, the hair should be cut short to prevent matting and decomposition
of the crusts.
The papules do not maturate so well when protected from the light, and
for centuries attempts have been made to modify the course of the pustules, by
either excluding the light, or by changing its character. In the Middle Ages
Gilbertus Magnus and John of Gaddesden recommended wrapping the patient
in red flannel, and the latter treated in this way the son of Edward I. It was
an old practice of the Egyptians and Arabians to cover the exposed parts of
small-pox patients with gold-leaf. Lutzenberg, a distinguished New Orleans
physician, in 1832 treated patients by exclusion of the sunlight. Eecently the
red-light treatment of the disease has been advocated by Finzen. The state-
ments do not agree as to its value. Nash states that the course of the rash may
VACCINIA— VACCINATION. 123
be modified by the treatment, but Eicketts and Byles could see no influence
whatever, even in cases taken at the earliest possible date.
Complications. — If the diarrhoea is severe in children, paregoric may be
given. When the pulse becomes feeble and rapid, stimulants may be freely
given. The maniacal delirium may require chloroform or morphia, but for less
intense nervous symptoms the bath or cold pack is the best. For the severe
haemorrhages of the malignant cases nothing can be done, and it is only cruel
to drench the unfortunate patient with iron, ergot, and other drugs. Symp-
toms of obstruction in the larynx, usually from oedema, may call for tracheot-
omy. In the late stages of the disease, should the patient be extremely debili-
tated and the subject of abscesses and bed-sores, he may be placed on a water-
bed or treated in the continuous warm bath.
The care of the eyes is most important. The lids should be thoroughly
cleansed and the conjunctivae washed with a warm solution of salt or boracic
acid. In the confluent cases the eyelids are much swollen and glued together,
and it is only constant watchfulness which prevents keratitis. The mouth and
throat should be kept clean and the treatment of the nose with glycerin or
sweet oil should be begun early, as it prevents the formation of hard crusts.
The treatment in the stage of convalescence is important. Frequent bath-
ing helps to soften the crusts, and the skin may be oiled daily. Convalescence
should not be considered established until the skin is perfectly smooth and
clean and free from any trace of scabs.
V. VACCINIA (Cow-pox)— VACCINATION.
Definition. — An eruptive disease of the cow, the virus of which, inoculated
into man (vaccination), produces a local pock with constitutional disturbance,
which affords protection, more or less permanent, against small-pox.
The vaccine is got either directly from the calf — animal lymph — in which
the disease is propagated at regular stations, or is obtained from persons vac-
cinated (humanized lymph).
History. — For centuries it had been a popular belief among farmer folk
that cow-pox protected against small-pox. The notorious Duchess of Cleve-
land, replying to some joker who suggested that she would lose her occupation
if she was disfigured with small-pox, said that she was not afraid of the dis-
ease, as she had had a disease that protected her against small-pox. Jesty, a
Dorsetshire farmer, had had cow-pox, and in 1774 vaccinated successfully his
wife and two sons. Plett, in Holstein, in 1791, also successfully vaccinated
three children. When Jenner was a student at Sodbury, a young girl, who
came for advice, when small-pox was mentioned, exclaimed, " I can not take
that disease, for I have had cow-pox." Jenner subsequently mentioned the
subject to Hunter, who in reply gave the famous advice : " Do not think, but
try; be patient, be accurate." As early as 1780 the idea of the protective power
of vaccination was firmly impressed on Jenner's min,d. The problem which
occupied his attention for many years was brought to a practical issue when,
on May 14, 1796, he took matter from the hand of a dairy-maid, Sarah Nelmes,
who had cow-pox, and inoculated a boy named James Phipps, aged eight years.
On July 1st matter was taken from a small-pox pustule and inserted into
124 SPECIFIC INFECTIOUS DISEASES.
the bo}^, but no disease followed. In 1798 ajDpeared An Inquiry into the Causes
and Effects of the Variola Vaccinae, a Disease discovered in some of the West-
ern Counties of England, particularly Gloucestershire, and known by the jSTame
of Cow-pox (pp. iv, To, four plates, 4to. London, 1798).
In the United States cow-pox was introduced by Benjamin Waterhouse,
Professor of Physic at Harvard, who on July 8, 1800, vaccinated seven of his
children. In Boston on August 16, 1802, nineteen boys were inoculated with
the cow-pox. On Xovember 9th twelve of them were inoculated with small-
pox; nothing followed. A control experiment was made by inoculating two
unvaccinated boys with the same small-pox virus ; both took the disease. The
nineteen children of August 16th were again unsuccessfully inoculated with
fresh virus from these two boys. This is one of the most crucial experiments
in the history of vaccination, and fully justified the conclusion of the Board
of Health — cow-pox is a complete security against the small-pox.
Practitioners should familiarize themselves with the literature on vaccina-
tion. The centenary number of the British Medical Journal is particularly
valuable (1896). The report of the Eoyal Commission on vaccination (1897),
the exhaustive article in Allbutt's System by T. D. Acland and Copeman, and
Cory's recent monograph on the subject afford a large body of material. To
the public health officials, who wish for distribution in handy shape Facts
about Small-pox and Vaccination, leaflets issued by the British Medical
Association (British Medical Journal, 1898, vol. i, p. 632) will be of
the greatest value. The Vaccination Law of the German Empire, printed
in English (Berlin, B. Paul, 1904), contains important information and
statistics.
Nature of Vaccinia. — Is cow-pox a separate independent disease, or is it
only small-pox modified by passing through the cow? In spite of a host of
observations, this question is not yet settled, as may be seen in the diametrically
opposed views expressed by Copeman in Allbutt's System and by Brouardel in
the Twentieth Century Practice. The experiments may be divided into two
groups. First, those in which the inoculation of the small-pox matter in the
heifer produced pocks corresponding in all respects to the vaccine vesicles.
Lymph from the first calf inoculated into a second or third produced the char-
acteristic lesions of cow-pox, and from the first, second, or third animal lymph
used to vaccinate a child produced a typical localized vaccine vesicle without
any of the generalized features of small-pox. The experiments of Ceely, of
Babcock, and many other more recent workers seem to leave no question what-
ever that t3'pical vaccinia may be produced in the calf by the inoculation of
variolous matter. A great deal of the vaccine material at one time in use in
England was obtained in this way. Secondly, against this is urged Chauveau's
Lyons experiments. Seventeen young animals were inoculated with the virus
of small-pox. Small reddish papules occurred which disappeared rapidly, but
the animals did not acquire cow-pox. Fifteen of the seventeen animals were
also vaccinated. Of these only one showed a typical cow-pox eruption. To
determine the nature of the original papules one was excised and inoculated
into a non-vaccinated child, which developed as a result generalized confluent
small-pox. A second child inoculated from the primary pustule of the first
child developed discrete small-pox. The French still hold to the Lyons experi-
ments as demonstrating the duality of the diseases.
VACCINIA— VACCINATION. 125
The weight of evidence favors the view that cow-pox and horse-pox are
variola modified by transmission; or, as has been suggested, "small-pox and
vaccinia are both of them descended from a common stock — from an ancestor,
for instance — which resembled vaccinia far more than it resembled small-pox "
(Copeman).
The bodies described by Guarnieri have been very thoroughly studied by
Councilman and his colleagues, who regard them as forms of a protozoon —
Cytoryctes vaccinice — with a well characterized developmental cycle, increasing
in size until they undergo segmentation.
Normal Vaccination. — Period of Incubation. — At first there may be a little
irritation at the site of inoculation, which subsides. Period of Eruption. — On
the third day, as a rule, a papule is seen surrounded by a reddish zone. This
gradually increases, and on the fifth or sixth day shows a definite vesicle, the
margins of which are raised while the centre is depressed. By the eighth day
the vesicle has attained its maximum size. It is round and distended with a
limpid fluid, the margin hard and prominent, and the umbilication is more
distinct. By the tenth day the vesicle is still large and is surrounded by an
extensive areola. The contents have now become purulent. The skin is also
swollen, indurated, and often painful. On the eleventh or twelfth day the
hypersemia diminishes, the lymph becomes more opaque and begins to dry. By
the end of the second week the vesicle is converted into a brownish scab, which
gradually becomes dry and hard, and in about a week (that is, about the
twenty-first or twenty-fifth day from the vaccination) separates and leaves a
circular pitted scar. If the points of inoculation have been close together, the
vesicles fuse and may form a large combined vesicle. Constitutional symptoms
of a more or less marked degree follow the vaccination. Usually on the third
or fourth day the temperature rises, and may persist, increasing until the
eighth or ninth day. There is a marked leucocytosis. In children it is common
to have with the fever restlessness, particularly at night, and irritability; but
as a rule these symptoms are trivial. If the inoculation is made on the arm,
the axillary glands become large and sore; if on the leg, the inguinal glands.
The duration of the immunity is extremely variable, differing in different indi-
viduals. In some instances it is permanent, but a majority of persons within
ten or twelve years again become susceptible.
Pevaccination should be performed between the tenth and fifteenth year,
and whenever small-pox is epidemic. The susceptibility to revaecination is
very general. In 1891-^92 vaccination pustules developed in 88.7 per cent of
the newly enrolled troops of the German army, most of whom had been vac-
cinated twice in their lives before. The vesicle in revaecination is usually
smaller, has less induration and hypersemia, and the resulting sear is less per-
fect. Particular care should be taken to watch the vesicle of revaecination, as
it not infrequently happens that a spurious pock is formed, which reaches its
height early and dries to a scab by the eighth or ninth day.
Irregular Vaccination. — {a) Local Variations. — We occasionally meet
with instances in which the vesicle develops rapidly with much itching, has
not the characteristic flattened appearance, the lymph early becomes opaque,
and the crust forms by the seventh or eighth day. The evolu-tion of the pocks
may be abnormally slow. In such cases the operation should again be per-
formed with fresh lymph. The contents of the vesicles may be watery and
126 SPECIFIC INFECTIOUS DISEASES.
blood}'. In the involution the bruising or irritation of the pocks may lead to
ulceration and infiamniatioai. A very rare event is the recurrence of the pock
in the same place. Sutton reports four such recurrences within six months.
(5) Gexeralized Yaccinia. — It is not uncommon to see vesicles in the
vicinity of the primary sore. Less common is a true generalized pustular rash,
developing in different parts of the body, often beginning about the wrists and
on the back. The secondary pocks may continue to make their appearance for
five or six weeks after vaccination. In children the disease may prove fatal.
They may be most abundant on the vaccinated limb, and occur usually about
the eighth to the tenth day.
(c) CoMPLiCATioxs. — In unhealthy subjects, or as a result of uncleanli-
ness, or sometimes injury, the vesicles inflame and deep excavated ulcers result.
Sloughing and deep cellulitis may follow. In debilitated children there may
be with this a purpuric rash. Acland thus arranges the dates at which the
possible eruptions and complications may be looked for :
1. During the first three days: Erythema; urticaria; vesicular and bullous
eruptions ; invaccinated erysipelas.
2. After the third day and until the pock reaches maturity: Urticaria;
lichen urticatus, erythema multiforme ; accidental erysipelas.
3. About the end of the first week: Generalized vaccinia; impetigo; vac-
cinal ulceration; glandular abscess; septic infections; gangrene.
4. After the involution of the pocks : Invaccinated diseases — for example,
S}^hilis.
(d) Teaxsmissiox of Disease by Vaccixatiox. — S3^hilis has undoubt-
edly been transmitted by vaccination, but such instances are very rare. A large
number of the cases of alleged vaccino-syphilis must be thrown out. The ques-
tion has now become really of minor importance since the wide-spread use of
animal lymph. Dr. Cory's sad experiment may here be referred to. He vac-
cinated himself four times from sj^hilitic children. The first vaccination
followed, but no syphilis. Two other attempts (negative) were made. The
fourth time he was vaccinated from a child the subject of congenital s}^hilis.
The lymph was taken from the child's arm with care, avoiding any contamina-
tion with blood. At two of the points of insertion red papules aj)peared on
the twenty-first day. On the thirty-eighth day a little ulcer was found, which
Mr. Hutchinson decided was syphilitic. The diseased parts were then removed.
By the fiftieth day the constitutional s3'mptoms were well marked. Among
the differences between vaccino-syphilis and vaccination ulcers the most im-
portant is perhaps that the chancre never appears before the fifteenth day,
usually not until from three to five weeks, whereas the ulceration of ordinary
vaccination is present by the twelfth or fifteenth day. The loss of substance
in the chancre is usually quite superficial and the induration very parchment-
like and specific, with but a slight inflammatory areola. The glandular swell-
ing, too, is constant and indolent, while in the vaccination ulcer it is often
absent, or, when present, chiefly inflammatory.
Tuberculosis. — " Xo undoubted case of invaccinated tubercle was brought
before the Eoyal Commission on Vaccination" (Acland). The risk of trans-
mitting tuberculosis from the calf is so slight that it need not be considered.
The transmission of leprosy by vaccination is doubtful.
The observations on the presence of actinomyces in vaccine virus have been
VACCINIA— VACCINATION. 127
confirmed by W. T. Howard, Jr., who found it 34 times in 95 cultures from
the virus of five producers in the United States.
Tetanus. — McFarland has collected 95 cases, practically all American.
Sixty-three occurred in 1901, a majority of which could be traced to one source
of supply, in which E. W. Wilson demonstrated the tetanus bacillus. Most of
the cases occurred about Philadelphia. Since that date, McFarland tells me
that very few cases have been reported. The occurrence of this terrible com-
plication emphasizes the necessity of the most scrupulous care in the prepara-
tion of the animal virus, as the tetanus bacillus is almost constantly present in
the intestines of cattle.
(e) Influence op Vaccination upon other Diseases, — A quiescent
malady may be lighted into activity by vaccination. This has happened with
congenital syphilis, occasionally with tuberculosis. An old idea was prevalent
that vaccination had a beneficial influence upon existing diseases. Thomas
Archer, the first medical graduate in the United States, recommended it in
whooping-cough, and said that it had cured in his hands six or eight cases. At
the height of the vaccination convulsions may occur and be followed by hemi-
plegia. One such case I saw with Morris J. Lewis.
Choice of Lymph. — If bovine lymph is not available, humanized lymph
should be taken on the eighth day, and only from perfectly formed, unbroken
vesicles, which have had a typical course. Pricking or scratching the surface,
the greatest care being taken not to draw blood, allows the lymph to exude, and
it may be collected on ivory points or in capillary tubes. The child from
which the lymph is taken should be healthy, strong, and known to be of good
stock, free from tuberculous or syphilitic taint. The glycerinated calf lymph
has come into general use. The Local Government Board has recently issued
a valuable report on the subject by Thorne and Copeman, giving full details
as to the method of preparation. In it the statement is made that, whereas it
was usual to make the lymph from one calf serve for from 200 to 300 vaccina-
tions, the glycerinated lymph will serve for from 4,000 to 5,000 vaccinations.
Technique. — Far too little attention is paid in American schools to the
instruction of students in the art of vaccination. That part of the arm about
the insertion of the deltoid is usually selected for the operation. Mothers " in
society " prefer to have girl babies vaccinated on the leg. The skin should be
cleansed and put upon the stretch. Then, with a lancet or the ivory point,
cross-scratches should be made in one or more places. When the lymph has
dried on the points it is best to moisten it in warm water. The clothing of
the child should not be adjusted until the spot has dried, and it should be
protected for a day or two with lint or a soft handkerchief. If erysipelas is
prevalent, or if there are cases of suppuration in the same house, it is well to
apply a pad of antiseptic cotton. Vaccination is usually performed at the
second or third month. If unsuccessful, it should be repeated " from time to
time. A person exposed to the contagion of small-pox should always be revac-
cinated. This, if successful, will usually protect; but not always. The cases
in which small-pox is taken within a few years after vaccination are probably
instances of spurious vaccination.
The Value of Vaccination. — Sanitation can not account for the diminution
in small-pox and for the low rate of mortality. Isolation, of course, is a use-
ful auxiliary, but it is no substitute. Vaccination is not claimed to be an
128 SPECIFIC INFECTIOUS DISEASES,
invariable and permanent preventive of small-pox, but in an immense majority
of cases successful inoculation renders the person for many 3'ears insusceptible.
Communities in which vaccination and revaccination are thoroughly and sys-
tematically carried out are those in which small-pox has the fewest victims.
The German army since 187i, the date of the stringent laws, has enjoyed
practical immunity — not a single death from small-pox (to the date of the
last report, 1902), except an isolated case under peculiar circumstances in
1884-'8o. On the other hand, communities in which vaccination and revac-
cination are persistently neglected are those in which epidemics are most preva-
lent. Owing to a wide-spread prejudice against vaccination in Montreal, there
grew up, between the years 1876 and 1884, a considerable unprotected popu-
lation, and the materials were ripe for an extensive epidemic. The soil had
been prepared with the greatest care, and it only needed the introduction of
the seed, which in due time came with the Pullman-car conductor from Chi-
cago, on the 28th of February, 1885 (see page 113). Within the next ten
months thousands of persons were stricken with the disease, and 3,164 died.
Although the effects of a single vaccination may wear out, as we say, and
the individual again become susceptible to small-pox, yet the mortality in
such cases is very much lower than in persons who have never been vaccinated.
The mortality in persons who have been vaccinated is from 6 to 8 per cent,
whereas in the unvaccinated it is at least 35 per cent. There is evidence that
the greater the number of marks, the greater the protection in relation to
small-pox; thus the English Vaccination Eeport states that out of 4,754 cases
the death-rate T\dth one mark was 7.6 per cent; with two marks, 7 per cent;
with three marks, 4.2 per cent ; with four marks, 2.4 per cent. W. M. Welch's
statistics of 5,000 cases on this point give with good cicatrices 8 per cent;
with fair cicatrices, 14 per cent; with poor cicatrices, 27 per cent; post-vac-
cinal cases. 16 per cent; unvaccinated cases, 58 per cent.
VI. VARICELLA (CMcken-pox).
Definition. — An acute contagious disease of children, characterized by an
eruption of vesicles on the skin.
Etiology. — The disease occurs in epidemics, but sporadic cases are also
met with. It may prevail at the same time as small-pox or may follow or
precede epidemics of this disease. An attack of chicken-pox is no protection
against small-pox. It is a disease of childhood; a majority of the cases occur
between the second and sixth years. Adults who have not had the disease in
childhood are very liable to be attacked. The specific germ has not yet been
discovered.
There can be no question that varicella is an affection quite distinct from
variola and without at present any relation whatever to it. An attack of the
one does not confer immunity from an attack of the other. A boy, aged five,
was admitted to St. Thomas' Hospital with a vesicular eruption, and was iso-
lated in a ward on the same floor as the small -pox ward. The disease was
pronounced chicken-pox, however, by Eisdon Bennett and Bristowe. The
patient was then removed and vaccinated, with a result of four vesicles which
ran a pretty normal course. On the eighth day from the vaccination the child
VARICELLA. 129
became feverish. On the following day the papules appeared and the child
had a well-developed attack of small-pox with secondary fever (Sharkey).
Symptoms. — After a period of incubation of ten or fifteen days the child
becomes feverish and in some instances has a slight chill. There may be
vomiting, and pains in the back and legs. Convulsions are rare. The erup-
tion usually occurs within twenty-four hours. It is first seen upon the
trunk, either on the back or on the chest. It may begin on the forehead and
face. At first in the form of raised red papules, these are in a few hours
transformed into hemispherical vesicles containing a clear or turbid fluid. As
a rule there is no umbilication, but in rare instances the pocks are flattened,
and a few may even be umbilicated. They are often ovoid in shape and look
more superficial than the variolous vesicles. The skin in the neighborhood
is not often infiltrated or hypersemic. At the end of thirty-six or forty-eight
hours the contents of the vesicles are purulent. They begin to shrivel, and
during the third and fourth days are converted into dark brownish crusts,
which fall off and as a rule leave no scar. Fresh crops appear during the first
two or three days of the illness, so that on the fourth day one can usually see
pocks in all stages of development and decay. They are always discrete, and
the number may vary from eight or ten to several hundreds. As in variola,
a scarlatinal rash occasionally precedes the development of the eruption. The
eruption may occur on the mucous membrane of the mouth, and occasionally
in the larynx. In adults the disease may be much more severe, the initial
fever high, the rash very wide-spread, and the constitutional sjmiptoms com-
paratively severe, so that the diagnosis of variola may be made — the so-called
varicellse variolaformes.
There are one or two modifications of the rash which are interesting. The
vesicles may become very large and develop into regular bullae, looking not
unlike ecthyma or pemphigus (varicella bullosa). The irritation of the rash
may be excessive, and if the child scratches the pocks ulcerating sores may
form, which on healing leave ugly scars. Indeed, cicatrices after chicken-pox
are more common than after varioloid. The fever in varicella is slight, but
it does not as a rule disappear with the appearance of the rash. The course
of the disease is in a large majority of the cases favorable and no ill effects
follow. The disease may recur in the same individual. There are instances
in which a person has had three attacks.
In delicate children, particularly the tuberculous, gangrene (varicella
escharotica) may occur about the vesicles, or in other parts, as the scrotum.
Cases have been described of hsemorrhagic varicella with cutaneous ecchy-
moses and bleeding from the mucous membranes.
Nephritis may occur. Infantile hemiplegia has occurred during an attack
of the disease. Death has followed in an uncomplicated case from extensive
involvement of the skin.
The diagnosis is as a rule easy, particularly if the patient has been seen
from the outset. When a case comes under observation for the first time with
the rash well out, there may be considerable difficulty. The abundance of the
rash on the trunk in varicella is most important. The pocks in varicella are
more superficial, more bleb-like, have not so deeply an infiltrated areola about
them, and may usually be seen in all stages of development. They rarely at
the outset have the hard, shotty feeling of those of small-pox. The general
130 SPECIFIC INFECTIOUS DISEASES.
symptoms, the greater intensity of the onset, the prolonged period of invasion,
and the more frequent occurrence of prodromal rashes in small-pox are im-
portant points in the diagnosis.
Death is very rare, and, unless from the complications, raises a suspicion
of the correctness of the diagnosis. Thus of the 116 deaths in England and
Wales in 1903 ascribed to chicken-pox, it is probable, as Tatham suggests,
that many of these were from unrecognized small-pox.
No special treatment is required. If the rash is abundant on the face,
great care should be taken to prevent the child from scratching the pustules.
A soothing lotion should be applied on lint.
Vn. SCARLET FEVER.
Definition. — An infectious disease characterized by a diffuse exanthem and
an angina of variable intensity.
History. — In the sixteenth century Ingrasseas of Naples and Coyttar of
Poitiers recognized the disease; but Sydenham in 1675 gave a full account of
it under the name febris scarlatina.
Etiology. — Kg one of the acute infections varies so greatly in the intensity
of the outbreaks, a point to which both Sydenliam and Bretonneau called
attention. In some years it is mild; in others, with equally wide-spread epi-
demics, it is fearfully malignant. It is a wide-spread affection, occurring in
nearl}^ all parts of the globe and attacking all races.
Sporadic cases occur from time to time. The epidemics are most intense
in the autumn and winter. There is an extraordinary variability in the
severity of the outbreaks, which on the whole appear to be lessening in sever-
ity; thus in Boston from 1894 to 1903 the ratio of cases per ten thousand has
ranged from 45.80 to 16.18, and the mortality from 3.94 to .60. In England
and Wales in 1903 there were 4,158 deaths. Only in 1898, 1899, and 1900
did the deaths fall below 4,000. In 1883 they were between 12,000 and 13,000.
Seibert's studies in New York show that the disease increases steadily
from week to week until the middle of May ; the frequency diminishes gradu-
allj until the end of June, and gradually increases through October, Novem-
ber, and December. He associates the remarkable drop in July, August, and
September with the closure of the schools and the cessation of the daily con-
gregation of infectious material in small areas — school-houses and play-
grounds— for so many hours each day.
Age is the most important predisposing factor. Ninety per cent of the
fatal cases are under the tenth year. Sucklings are rarely attacked. The
general liability to the disease in childhood is less wide-spread than in measles.
Many escape altogether; others escape until adult life; some never take it.
Family susceptibility is not infrequently illustrated by the killing in rapid
succession of four or five members. On the other hand, individual resistance
is common, and many physicians constantly exposed escape. An attack as a
rule confers subsequent immunity. In rare instances there have been one or
even two recurrences.
The natives of India are said to enjoy comparative immunity.
Infedivity. — It is not yet accurately known where in the body the poison
is formed, how it is given off, or in what form it is taken by another person.
SCARLET FEVER. 131
It is probably given off with the secretions of the nose, throat, and respiratory
tract. The mild angina of the ambulatory cases may convey the disease, and
in this way it is spread in schools, and the " return cases," to be referred to
later, may find in this way their explanation. Much more attention has be^n
paid of late to this aspect of the scarlatinal infection, and it has even been
suggested that the skin is only infective by contamination with the secre-
tions. The general opinion, however, is that the poison is given off chiefly
from the skin, particularly when desquamating. Unlike measles, the germ
is very resistant and clings tenaciously to clothing, to bedding, the furni-
ture of the room, etc. Even after the most complete disinfection possible,
children who have been removed from an infected house may catch the
disease on their return. The possibility here of throat infection must
be considered. A third person may convey the disease, but undoubted
instances are rare, I recall one instance in which I could have been the only
possible medium. In a collective investigation on this point among physi-
cians in the State of Connecticut, Loveland had 100 negative and 10 positive
replies.
The disease is stated to have been conveyed by milk. Of 99 epidemics
studied by Kober the disease prevailed in 68 either at the dairy or the milk
farm. There appear to be two groups of cases: first, genuine scarlet fever,
in which the infection is conveyed through the milk having come in contact
with infected persons; and secondly, outbreaks of an infection resembling
scarlet fever, due to disease of the udder of the cows.
By surgical scarlatina, first brought to the attention of the profession by
Sir James Paget in 1864, is understood an erythematous eruption following
an operation or occurring during septic infection. It differs from medical
scarlatina in the large number of adults attacked, the shorter incubation,
the mildness of the throat symptoms, the starting of the eruption at the
wound, and the precocious desquamation. Alice Hamilton, after analyzing
174 cases reported in the literature, concludes that the eruption is most fre-
quently due to septic infection and is not truly scarlatinal, and that in those
cases in which the disease was undoubtedly scarlatina there is no convincing
evidence that the relation between the wound and the scarlet fever was any-
thing more than one of coincidence.
The specific germ is not known. It is claimed to be only a modified
streptococcus infection. The streptococcus pyogenes has often been found
in the blood during life and after death, and it is constantly present in the
throat in severe cases; but there is no agreement on the subject among the
best workers. Mallory's researches may point to a solution of the problem.
In four cases he found between the epithelial cells of the epidermis a proto-
zoon which formed definite rosettes like the malarial parasite. Duval, con-
tinuing these observations, has found this organism in the serum of blisters
on the skin of scarlet fever patients, and has traced it through a cycle of
changes which show at any rate that it is a definite parasite. Controls were
negative in other diseases. Whatever the germ may be, there is no question
that in severe cases the streptococcus infection plays an important role in
causing the septic symptoms of the disease.
Morbid Anatomy. — Except in the haemorrhagie form, the skin after death
shows no traces of the rash. There are no specific lesions. Those which
132 SPECIFIC INFECTIOUS DISEASES.
occur in the internal organs are due partly to the fever and partly to infec-
tion with pus-organisms.
The anatomical changes in the throat are those of simple inflammation,
follicular tonsillitis, and, in extreme grades, of diphtheroid angina. In
severe cases there is intense lymphadenitis and much inflammatory oedema
of the tissues of the neck, which may go on to suppuration, or even to gan-
grene. Streptococci are found abundantly in the glands and in the foci of
suppuration. The lymph glands and the lymphoid tissue may show hyper-
plasia, and the spleen, liver, and other organs may be the seat of wide-spread
focal necroses.
Endocarditis and pericarditis are not infrequent. Myocardial changes
are less common. The renal changes are the most important, and have been
thoroughly studied by Coats, Klebs, Wagner, and others. The special nephri-
tis of scarlet fever will be considered with the diseases of the kidney.
Affections of the respiratory organs are not frequent. When death results
from the pseudo-membranous angina, broncho-pneumonia is not uncommon.
Cerebro-spinal changes are rare.
Symptoms. — Incubation. — " From one to seven days, oftenest two to
four."
Invasion. — The onset is as a rule sudden. It may be preceded by a
slight, scarcely noticeable, indisposition. An actual chill is rare. Vomit-
ing is one of the most constant initial symptoms; convulsions are common.
The fever is intense ; rising rapidly, it may on the first day reach 104° or even
105°. The skin is unusually dry and to the touch gives a sensation of very
pungent heat. The tongue is furred, and as early as the first day there may
be complaint of dryness of the throat. Cough and catarrhal symptoms are
uncommon. The face is often flushed and the patient has all the objective
features of an acute fever.
Eruption. — Usually on the second day, in some instances within the
first twenty-four hours, the rash appears in the form of scattered red points
on a deep subcuticular flush ; at first on the neck and chest, and spreading
so rapidly that by the evening of the second day it may have invaded the
entire skin. After persisting for two or three days it gradually fades. At
its height the rash has a vivid scarlet hue, quite distinctive and unlike that
seen in any other eruptive disease. It is an intense hypersemia, and the anse-
mia produced by pressure instantly disappears. There may be fine puncti-
form haemorrhages, which do not disappear on pressure. In some cases the
rash does not become uniform but remains patchy, and intervals of normal
skin separate large hypergemic areas. Tiny papular elevations may some-
times be seen, but they are not so common as in measles. With each day
the rash becomes of a darker color, and there may be in parts even a bluish-
red shade. Smooth at the beginning, the skin gradually becomes rougher,
and to the touch feels like " goose skin." At the height of the eruption
sudaminal vesicles may develop, the fluid of which may become turbid. The
entire skin may at the same time be covered with small yellow vesicles on a
deep red background — scarlatina miliaris. McCollom lays stress upon the
appearance of a punctate eruption in the arm-pits, groins, and on the roof of
the mouth as positive proof of scarlet fever.
Occasionally there are petechias, which in the malignant t}^e of the dis-
SCARLET FEVER.
133
Day
1
^
3
-4
5
G
7
8
9
' 106'-
loC
loi
100
98°
^
v>
A
A
1
Y
J
'\
Y
\
v
^
1
V
->
V
-N
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^^
Chart VIII. — Scarlet Fever.
ease become wide-spread and large. The eruption does not always appear upon
the face. There may be a good deal of swelling of the skin, which feels uncom-
fortable and tense. The itching is variable ; not as a rule intense at the height
of the eruption. By the seventh or eighth day the rash has disappeared.
The mucous membrane of the pal-
ate, the cheeks, and the tonsils pre-
sent a vivid red, punctiform ap-
pearance. The tongue at first is red
at the tip and edges, furred in the
centre; and through the white fur
are often seen the swollen red papil-
lae, which give the so-called " straw-
berry^' appearance to the tongue,
particularly if the child puts out
the tip of the tongue between the
lips. In a few days the " fur "
desquamates and leaves the surface
red and rough, and it is this condi-
tion which some writers call the
" strawberry," or, better, the " rasp-
berry" tongue. Enlargement of the papillas was the only constant sign in
1,000 cases (McCollom). The breath often has a very heavy, sweet odor.
The pharyngeal symptoms are —
1. Slight redness, with swelling of the pillars of the fauces and of the
tonsils. 2. A more intense grade of swelling and infiltration of these parts
with a follicular tonsillitis. 3. Diphtheroid angina with intense inflamma-
tion of all the pharyngeal structures and swelling of the glands below the
jaw, and in very severe cases a thick brawny induration of all the tissues of
the neck.
The fever, which sets in with such suddenness and intensity, may reach
105° or even 106°. It persists with slight morning remissions, gradually
declining with the disappearance of the rash. In mild cases the tempera-
ture may not reach 103°; on the other hand, in very severe cases there
may be hyperpyrexia, the thermometer registering 108° or before death
even 109°.
The pulse ranges from 130 to 150; in severe cases with very high fever
from 190 to 200. The respirations show an increase proportionate to the
intensity of the fever. A leucocytosis is usually present, which may be high
(30,000 to 50,000 per c.cm.) in the severe cases. The gastro-intestinal symp-
toms are not marked after the initial vomiting, and food is usually well taken.
In some instances there are abdominal pains. The edge of the spleen may
be palpable. The liver is not often enlarged. With the initial fever nervous
symptoms are present in a majority of the cases; but as the rash comes out
the headache and the slight nocturnal wandering disappear. The urine has
the ordinary febrile characters, being scanty and high colored. Slight albu-
minuria is by no means infrequent during the stage of eruption. Careful
examination of the urine should he made every day. There. is no cause for
alarm in the trace of albumin which is so often present, not even if it is asso-
ciated with a few tube-casts.
134 SPECIFIC INFECTIOUS DISEASES.
Desqua:matiox. — With the disappearance of the rash and the fever the
skin looks somewhat stained, is dry, a little rough, and gradually the upper
layer of the cuticle begins to separate. The process usually begins about the
neck and chest, and flakes are gradually detached. The degree and character
of the desquamation bear some relation to the intensity of the eruption. "Wlien
the latter has been very vivid and of long standing, large flakes ma}^ be thrown
off. In rare instances the hair and even the nails have been shed. It must
not be forgotten that there are cases in which the desquamation has been
prolonged, according to Trousseau, even to the seventh or eighth week. The
entire process lasts from ten to fifteen or even twenty days.
Atypical Scarlet Fever. — ]\Iild axd Abortive FoE:krs. — In cases of excep-
tional mildness the rash may be scarcely perceptible. During epidemics, when
several children of a household are affected, one child sickens as if with scar-
let fever, and has a sore throat and the " strawberry tongue," but the rash
does not appear — scarlatina sine eruptione. In school epidemics a third or
more of the cases may be without the rash. Desquamation, however, may
follow, and in these very mild forms nephritis ma}^ occur.
Malignant Scaelet Fever. — Fulminant Toxic Variety. — With all the
characteristics of an acute intoxication, the patient is overwhelmed by the
intensit}^ of the poison and may die within twenty-four or thirty-six hours.
The disease sets in with great severity — ^liigh fever, extreme restlessness,
headache, and delirium. The temperature may rise to 107° or even 108°, in
rare cases even higher. Convulsions may occur and the initial delirium rap-
idly gives place to coma. The dyspnoea may be urgent; the pulse is very
rapid and feeble.
HEMORRHAGIC FoRZsi. — HEBmorrliages occur into the skin, and there are
hgematuria and epistaxis. In the erjihematous rash scattered petechise appear,
which gradually become more extensive, and ultimately the skin may be uni-
versally involved. Death may take place on the second or on the third day.
While this form is perhaps more common in enfeebled children, I have twice
known it to attack adults apparently in full health.
Angixose Form. — The throat s^nnptoms appear early and progress rap-
idly; the fauces and tonsils swell and are covered with a thick membranous
exudate, which may extend to the posterior wall of the phar^mx, forward into
the mouth, and upward into the nostrils. The glands of the neck rapidly
enlarge. Kecrosis occurs in the tissues of the throat, the foetor is extreme,
the constitutional disturbance profound, and the child dies with the clin-
ical picture of a malignant diphtheria. Occasionally the membrane extends
into the trachea and the bronchi. The Eustachian tubes and the middle
ear are usually involved. When death does not take place rapidlj^ from tox-
aemia there may be extensive abscess formation in the tissues of the neck and
sloughing. In the separation of deep sloughs about the tonsils the carotid
artery may be opened, causing fatal hemorrhage.
Complications and Sequelae. — {a) Xephritis. — At the height of the fever
there is often a slight trace of albumin in the urine, which is not of special
significance. In a majorit)'- of cases the kidneys escape without greater dam-
age than occurs in other acute febrile affections.
iS^ephritis is most common in the second or third week and may follow
a very mild attack. It may be dela^^ed until the third or fourth week. As
SCARLET FEVER. I35
a rule, the earlier it occurs the more severe the attack. It occurs in from
10 to 20 per cent of the cases. Three grades of cases may be recognized :
1. Acute hsemorrhagic nephritis. There may be suppression of urine or
only a small quantity of bloody fluid laden with albumin and tube-casts.
Vomiting is constant, there are convulsions, and the child dies with the symp-
toms of acute uraemia. In severe epidemics there may be many cases of this
sort, and an acute, rapidly fatal, nephritis due to the scarlet fever poison may
occur without an exanthem.
2. Less severe cases without serious acute symptoms. There is a puffy
appearance of the eyelids, with slight oedema of the feet; the urine is dimin-
ished in quantity, smoky, and contains albumin and tube-casts. The kidney
symptoms then dominate the entire case, the dropsy persists, and there may
be effusion into the serous sacs. The condition may drag on and become
chronic, or the patient may succumb to urgemic accidents. Fortunately, in
a majorit}'^ of the cases recovery takes place.
3. Cases so mild that they can scarcely be termed nephritis. The urine
contains albumin and a few tube-casts, but rarely blood. The oedema is ex-
tremely slight or transient, and the convalescence is scarcely interrupted.
Occasionally, however, serious symptoms may supervene. Oedema of the glot-
tis may prove rapidly fatal, and in one case of the kind a child under my care
died of acute effusion into the pleural sacs.
In other cases the oedema disappears and the child improves, though he
remains pale, and a slight amount of albumin persists in the urine for months
or even for years. Eecovery may ultimately take place or a chronic inter-
stitial nephritis may follow.
Occasionally oedema occurs without albuminuria or signs of nephritis.
Possibly it may be due to the anaemia; but there are instances in which
marked changes have been found in the kidney after death, even when the
urine did not show the features characteristic of nephritis.
( & ) Arthritis. — There are two forms : first, the severe scarlatinal
pygemia, with suppuration of one or more joints — part of a wide-spread strep-
tococcus infection. This is an extremely serious and fatal form. Secondly,
the true scarlatinal rheumatism, so-called, an arthritis analogous to that
occurring in gonorrhoea and other infections. It occurs in the second or third
week; many joints are attacked, particularly the small joints of the hands.
The heart may be involved. Chorea, subcutaneous fibroid nodules, purpura,
and pleurisy may be complications. The outlook is usually good.
(c) Cardiac Complications. — In the severe septic cases a malignant
endocarditis, sometimes with purulent pericarditis, closes the scene. Simple
endocarditis is not uncommon. It may not be easy to say whether the apex
systolic murmur, so often heard, signifies a valvular lesion. The persistence
after convalescence, with signs of slight enlargement of the heart, may alone
decide that the murmur indicated an organic change. As is the rule, such
cases give no symptoms. And, lastly, there may be a severe toxic myo-
carditis, sometimes leading to acute dilatation and sudden death. It is
to be borne in mind that the cardiac complications of the disease are often
latent.
(d) Acute Bronchitis and Broncho-pneumonia are not common.
Empyema is an insidious and serious complication.
136 SPECIFIC INFECTIOUS DISEASES.
(e) Ear Complications. — Common and serious, due to extension of the
inflammation from the throat through the Eustachian tubes, they rank among
the most frequent causes of deafness in children. The severe forms of mem-
branous angina are almost always associated with otitis, which goes on to
suppuration and to perforation of the drum. The process may extend to the
labyrinth and rapidly produce deafness. In other instances there is suppura-
tion in the mastoid cells. In the necrosis which follows the middle-ear dis-
ease, the facial nerve may be involved and paralysis follow. Later, still more
serious comjDiications may follow, such as thrombosis of the lateral sinus,
meningitis, or abscess of the brain.
(/) Adenitis. — In comparatively mild cases of scarlet fever the sub-
maxillary lymph-glands may be swollen. In severer cases the swelling of the
neck becomes extreme and extends beyond the limits of the glands. Acute
phlegmonous inflammations may occur, leading to wide-spread destruction of
tissue, in which vessels may be eroded and fatal haemorrhage ensue. The sup-
purative processes may also involve the retro-pharyngeal tissues.
The swelling of the lymph-glands usually subsides, and within a few weeks
even the most extensive enlargement gradually disappears. There are rare
instances, however, in which the lymphadenitis becomes chronic, and the
neck remains with a glandular collar which almost obliterates its outline.
This may prove intractable to all ordinary measures of treatment. A case
came under my observation in which, two years after scarlet fever, the neck
was enormously enlarged and surrounded by a mass of firm brawny glands.
{g) Nervous Complications. — Chorea occasionally complicates the
arthritis and endocarditis. Sudden ' convulsions followed by hemiplegia may
occur. In seven of my series of 130 cases of infantile hemiplegia the trouble
came on during scarlet fever. Progressive paralysis of the limbs with wasting
may present the features of a subacute, ascending spinal paralysis. Throm-
bosis of the cerebral veins may occur. Mental symptoms, mania and melan-
cholia, have been described.
(h) Other rare complications and sequelae are oedema of the eyelids, with-
out nephritis (S. Phillips), symmetrical gangrene, enteritis, noma, and per-
foration of the soft palate (Goodall). Pearson and Littlewood have reported
a case of dry gangrene after scarlet fever in a boy of four, which occurred
on the ninth day of the disease, and involved both legs, necessitating amputa-
tion at the upper third of the thighs. The child recovered.
(i) The fever may persist for several weeks after the disappearance of
the rash, and the child may remain in a septic or typhoid state. This so-called
scarlatinal typhoid is usually the result of some chronic suppurative process
about the throat or the nose, occasionally the result of a chronic adenitis, and
in a few eases nothing whatever can be found to account for the fever.
Relapse is rare. It was noted in 7 per cent of 12,000 (Caiger), and in
1 per cent of 1,520 cases (IsTewshohne).
Diagnosis. — The diagnosis of scarlet fever is not difficult, but there are
cases in which the true nature of the disease is for a time doubtful. The fol-
lowing are the most common conditions with which it may be confounded :
1. Acute Exfoliating Dermatitis. — This pseudo-exanthem simulates
scarlet fever very closely. It has a sudden onset, with fever. The eruption
spreads rapidly, is uniform, and after persisting for five or six days begins
SCARLET FEVER. 137
to fade. Even before it has entirely gone, desquamation usually begins.
Some of these cases can not be distinguished from scarlet fever in the stage
of eruption. The throat symptoms, however, are usually absent, and the
tongue rarely shows the changes which are so marked in scarlet fever. In the
desquamation of this affection the hair and nails are commonly affected, it
is, too, a disease liable to recur. Some of the instances of second and third
attacks of scarlet fever have been cases of this form of dermatitis.
2. Measles, which is distinguished by the longer period of invasion, the
characteristic nature of the prodromes, and the later appearance of the rash.
The greater intensity of the measly rash ' upon the face, the more papular
character and the irregular crescentic distribution are distinguishing features
in a majority of the cases. Other points are the absence in measles of the
sore throat, the peculiar character of the desquamation, the absence of leuco-
cytosis, and the presence of Koplik's sign.
3. EoTHELN.— The rash of rubella is sometimes strikingly like that of
scarlet fever, but in the great majority of cases the mistake could not arise.
In cases of doubt the general symptoms are our best guide.
4. Septicemia. — As already mentioned, the so-called puerperal or sur-
gical scarlatina shows an eruption which may be identical in appearance with
that of true scarlet fever.
5. Diphtheria. — The practitioner may be in doubt whether he is deal-
ing with a case of scarlet fever with intense membranous angina, a true diph-
theria with an erythematous rash, or coexisting scarlet fever and diphtheria.
In the angina occurring early in, and during the course of scarlet fever,
though the clinical features- may be those of true diphtheria, Loeffler's bacilli
are rarely found. On the other hand^ in the membranous angina occurring
during convalescence, the bacilli are usually present. The rash in diphtheria
is, after all, not so common, is limited usually to the trunk, is not so persist-
ent, and is generally darker than the scarlatinal rash.
Scarlatina and diphtheria may coexist, but in a case presenting wide-spread
erythema and extensive membranous angina with Loeffler's bacilli, it would
puzzle Hippocrates to say whether the tAvo diseases coexisted, or whether it
was only an intense scarlatinal rash in diphtheria. Desquamation occurs in
either case. The streptococcus angina is not so -apt to extend to the larynx,
nor are recurrences so common; but it is well to bear in mind that general
infection may occur, that the membrane may spread doAAOiward with great
rapidity, and, lastly, that all the nervous sequelae of the Klebs-Loeffler diph-
theria may follow the streptococcus form.
6. Drug Eashes. — These are partial, and seldom more than a transient
hypersemia of the skin. Occasionally they are diffuse and intense, and in such
cases very deceptive. They are not associated, however, with the characteristic
symptoms of invasion. There is no fever, and with care the distinction can
usually be made. They are most apt to follow the use of belladonna, quinine,
and iodide of potassium. The antitoxin erythema is a frequent cause of
doubt, particularly in hospitals for infectious diseases.
Coexistence of other Diseases. — Of 48,366 cases of scarlet fever in the
Metropolitan Asylum Board Hospitals which were complicated by some other
disease, in 1,094 cases the secondary infection was cliphtheria, in 899 cases
chicken-poxj in 703 measles, in 404 whooping-cough, in 55 erysipelas, in H
138 SPECIFIC INFECTIOUS DISEASES.
enteric fever, and in 1 typlms fever (F. F. Caiger). Farnarier (190J:) could
collect onJ.y 39 undoubted cases of the coexistence of typhoid and scarlet fever.
Hovj Long is a Child Infective^ — ^Usually after desquamation is complete,
in four or five weeks the danger is thought to be over, but the occurrence of
so-called " return cases " shows that patients remain infective even at this
stage. In 1894, vrith 2,593 patients from the Glasgow fever hospitals sent
to their homes convalescent, fresh cases appeared in 70 of the houses (Chal-
mers). With 15,000 cases submitted to an average period of isolation of
forty-nine days or under, the percentage of return cases was 1.86 ; with an
average period of fifty to fifty-six days, the percentage was 1,12; where the
isolation extended to between fifty-seven and sixty-five days, the percentage
of return cases was 1 (l!^eech). This author suggests eight weeks as a mini-
mum and thirteen weeks as a maximum. Special care should be taken of
cases with rhinorrhoea and otorrhoea and throat trouble, as the secretions from
these parts are probablj^ of greater importance than the skin in the conveyance
of the disease.
Prognosis. — The death-rate has been falling of late years. Epidemics
differ remarkably in severit}^ and the mortality is extremely variable. Among
the better classes the death-rate is much lower than in hospital practice. There
are physicians who have treated consecutively a hundred or more cases vrith-
out a death. On the other hand, in hospitals and among the poorer classes
the death-rate is considerable, ranging from 5 or 10 per cent in mild epidemics
to 20 or 30 per cent in the very severe. In 1,000 cases reported from the
Boston City Hospital by McCoUom, the death-rate was 9.8 per cent. There
is a curious variability in the local mortality from this disease. In England,
for example, in some j'^ears, certain counties enjoy almost immunity from
fatal scarlet fever. The younger the child the greater the danger. In infants
under one year the death-rate is ver}^ high. The great proportion of fatal
cases occurs in children under six years of age. The unfavorable symptoms
are very high fever, early mental disturbance with gTcat jactitation, the occur-
rence of hEemorrhages (cutaneous or visceral), intense diphtheroid angina
with cervical bubo, and signs of lar}Tigeal obstruction. Xephritis is always a
serious complication, and when setting in with suppression of the urine may
quickly prove fatal; a large majority of the cases recover.
Prophylaxis. — Much may be done to prevent the spread of the disease if
the physician exercises scrupulous care in each case. Much is to be expected
from a rigid system of school inspection, and from the more general recogni-
tion of the importance of the latent cases and the persistence of the infection
in the secretions of the nose and throat. The attendant in a case of scarlet
fever should take the most careful precautions against the conveyance of the
disease, wearing a govm in the room and thoroughly washing the hands and
face after leaving the room. To the very busy practitioner the minutiae of
proper disinfection are very irksome, but it is his duty to carry out the most
rigid disinfection possible, and intelligent people now expect it.
Treatment. — The case may be treated at home or sent to an isolation hos-
pital. The difficulty in liome treatment is in securing complete isolation. The
risks are well illustrated by the careful studies of Chap in, of Providence, who
found that during eight years 26.1 per cent of the 4,412 persons under twenty-
one years of age in infected families took the disease. When practicable, it
SCARLET FEVER. 139
is better to send the other children out of the house. Chapin's experience on
this point is most interesting. In seventeen years, from 653 families infected
with scarlet fever, 1,051 children, none of whom had had the disease, were
removed. Only 5 per cent were attacked while away from home. Nineteen
who had been sent away from the infected houses were attacked on their
return.
Hospital treatment is not carried out to any great extent in the United
States. In Great Britain a very considerable proportion of all patients are
removed from their homes. In the segregation hospital groups of patients,
from ten to twenty, are treated in separate wards. In the true isolation hos-
pital each patient is in a separate room, and patients with different infectious
diseases may be in adjacent rooms.
The disease can not be cut short. In the presence of the severer forms we
are still too often helpless. There is no disease, however, in which the suc-
cessful issue and the avoidance of complications depend more upon the skilled
judgment of the physician and the care with which his instructions are car-
ried out.
The child should be isolated and placed in charge of a competent nurse.
The temperature of the room should be constant and the ventilation thorough.
The child should wear a light flannel night-gown, and the bedel othing should
not be too heavy. The diet should consist of milk, broths, and fresh fruits;
water should be freely given. With the fall of the temperature, the diet may
be increased and the child may gradually return to ordinary fare. When
desquamation begins the child should be thoroughly rubbed every day, or
every second day, with sweet oil, or carbolated vaseline, or a 5-per-cent hydro-
naphthol soap, which prevents the drying and the diffusion of the scales.
A 5- or 10-per-cent solution of ichthyol in lanolin may be used. An occasional
warm bath may then be given. At any time during the attack the skin may
be sponged with warm water. The patient may be allowed to get up after the
temperature has been normal for ten days, but for at least three weeks from
this time great care should be exercised to prevent exposure to cold. It must
not be forgotten, also, that the renal complications are very apt to occur dur-
ing the convalescence, and after all danger is apparently past. Ordinary cases
do not require any medicine, or at the most a simple fever mixture, and dur-
ing convalescence a bitter tonic. The bowels should be carefully regulated.
Special symptoms in the severe cases call for treatment.
When the fever is above 103° the extremities may be sponged with tepid
water. In severe cases, with the temperature rapidly rising, this will not
suffice, and more thorough measures of hydrotherapy should be practised.
With pronounced delirium and nervous symptoms the cold pack should be
used. When the fever is rising rapidly but the child is not delirious, he should
be placed in a warm bath, the temperature of which can be gradually lowered.
The bath with the water at 80° is beneficial. In giving the cold pack a rubber
sheet and a thick layer of blankets should be spread upon a sofa or a bed, and
over them a sheet wrung out of cold water. The naked child is then laid
upon it and wrapped in the blankets, ^n intense glow of heat quickly follows
the preliminary chilling, and from time to time the blankets may be unfolded
and the child sprinkled with cold water. The good effects which follow this
plan of treatment are often striking, particularly in allaying the delirium and
140 SPECIFIC INFECTIOUS DISEASES.
jactitation, and procuring quiet and refreshing sleep. Parents will ol)ject less,
as a rule, to the warm bath gradually cooled than to any other form of hydro-
theraj^y. The child ma}^ be removed from the warm liath, placed upon a sheet
wrung out of tolerably cold water, and then folded in blankets. The ice-cap
is very useful and may be kept constantly applied in cases in which there is
high fever. Medicinal antipyretics are not of much service in comparison with
cold water.
The throat s}Tnptoms, if mild, do not require much treatment. If severe,
the local measures mentioned under diphtheria should be used. A SO-per-
cent alcoholic solution of resorcin may be thoroughly swabbed into the naso-
pharjTix. It should be used every three or four hours in severe cases. Cold
applications to the neck are to be preferred to hot, though it is sometimes diffi-
cult to get a child to submit to them. In connection with the throat, the ears
should be specially looked after, and a careful disinfection of the mouth and
fauces by suitable antiseptic solutions should be practised. When the inflamma-
tion extends through the tubes to the middle ear, the practitioner should either
himself examine daily the condition of the drum, or, when available, a special-
ist should be called in to assist him in the case. The careful watching of this
membrane day by day and the puncturing of it if the tension becomes too
great may save the hearing of the child. With the aid of cocaine the drum
is readily punctured. The operation may be repeated at intervals if the pain
and distention return. No complication of the disease is more serious than
this extension of the inflammatory process to the ear.
The nephritis should be dealt with as in ordinary cases; indications for
treatment will be found under the appropriate section. It is worth men-
tioning, however, that Jaccoud insists upon the great value of milk diet in
scarlet fever as a preventive of nephritis.
Among other indications for treatment in the disease is cardiac weakness,
which is usually the result of the direct action of the poison, and is best met
by stimulants.
Seeujii Treatment. — On the view that the disease, or at any rate some
of its serious features, are caused by the streptococcus, attempts have been
made to prepare a curative serum by Marmorek, Aronson, Moser, and others.
Moser's serum, which has been used extensively in Escherich's clinic in
Vienna, is a polyvalent serum prepared from a number of definite tj^es of
streptococci. From iSTovember, 1900, to July, 1904, of 1,069 cases, 228 re-
ceived the serum treatment, usually the severer or lethal cases. The mortality
for the four years before the serum treatment averaged 14.5 per cent, for the
four years since its emploj^ment 8 per cent (H. L. K. Shaw).
VIII. MEASLES.
(Morbilli. Rubeola.)
Definition. — An acute, highly contagious fever with specific localization
in the upper air passages and in the skin.
History. — Ehazes, an Arabian physician, in the ninth century described
the disease with small-pox, of which it was believed to be a mild form, until
Sydenham separated them in the seventeenth century.
MEASLES. 141
Etiology. — As a cause of death measles ranks high among the acute fevers
of children. In 1903 there were 9,150 deaths from measles in England and
Wales, being fewer by 1,559 than the decennial average number. Ninety-four
per cent of the total deaths were in children under five years of age (Tatham).
The liability to infection is almost universal in persons unprotected by a
previous attack. It is a disease of childhood, but, as shown in the wide-spread
epidemics in the Faroe Islands and in the Fiji Islands, unprotected adults of
all ages are attacked. Within the first three months of life there is a relative
immunity. Occasionally infants of a month or six weeks take the disease.
Intra-uterine cases have been described, and a mother with measles may give
birth to a child with the eruption, or the rash may appear in a few days.
The disease is endemic in cities, and becomes epidemic at intervals, pre-
vailing most extensively in the cooler months, though this is by no means a
fixed rule.
The germ of the disease is unknown. The contagion is present in the
blood and secretions, and in the skin. In the eighteenth century Monro and
others demonstrated the inoculability of the disease. Direct contagion is the
most common. The poison is probably not in the expired air, but in the
particles of mucus and in tile sputum and the secretions of the mouth and
nose, which, dried, are conveyed with the dust. An all-important point is
the contagiousness of the disease in the pre-eruptive stage. A child with only
the catarrhal symptoms may be at school and a source of active infection.
Indirect contagion by means of fomites is very common. Measles may be
thus conveyed by a third person, by clothes, and by infected toys. The germs
of measles soon lose their virulence.
Eecurrence is rare. Very many cases of the supposed second and third
attack represent mistakes in diagnosis. Eelapse is occasionally seen, the symp-
toms recurring at intervals from ten to forty days; but it is not always easy
to say in a given case whether there may not have been new infection from
without.
Morbid Anatomy. — The catarrhal and inflammatory appearances seen post
mortem have nothing characteristic. Fatal cases show, as a rule, broncho-
pneumonia and an intense bronchial catarrh. The lymphatic elements all over
the body are swollen, the tonsils, the lymph glands, and the solitary and agmi-
nated follicles of the intestines. The spleen is rarely much enlarged. During
convalescence latent tuberculous foci are very apt to become active.
Symptoms. — Incubation. — " From seven to eighteen days ; of tenest four-
teen." The child shows no special changes. A leucocytosis has been observed,
and the pulse is said to be slow.
Invasion. — In this period, lasting from three to four days, very rarely
five or six, the child presents the symptoms of a feverish cold. The onset
may be insidious, or it may start with great abruptness, even with a con-
vulsion. There is not often a definite chill. Headache, nausea, and vomit-
ing may usher in the severe cases. The common catarrhal symptoms are
sneezing and running at the nose, redness of the eyes and lids, and cough.
The fever is .slight at first, but gradually there is pungent heat of the skin
with turgescence of the face. Prodromal rashes precede the true eruption in
a few cases, usually a blotchy erythema or scattered macules. The tongue is
furred and the mucous membranes of the mouth and throat are hypergemic,
142
SPECIFIC INFECTIOUS DISEASES.
Day
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and frequently show a distinct punctiform rash. The fever of the stage
of invasion may rise abruptly; more frequently it takes twenty-four or
forty-eight hours to reach the fastigium. The pulse-rate increases with
the fever, and may reach 140 or 160 per minute, gradually falling with
defervescence.
Eruption-. — " The symptoms increase till the fourth day. At that period
(although sometimes a day later) little red spots, just like flea-bites, begin to
come out on the forehead and the rest of the face. These increase both in size
and number, group themselves in clus-
ters, and mark the face with largish
red spots of different figures. These
red spots are formed by small red
papules, thick set, and just raised
above the level of the skin. The fact
that they really protrude can scarcely
be determined by the eye. It can,
however, be ascertained by feeling the
surface with the fingers. From the
face — where the}^ first appear — these
spots spread downward to the breast
and belly; afterward to the thighs
and legs" (Sydenham). The pap-
ules may feel quite shotty, but do not
extend deeply. On the trunk and ex-
tremities the swelling of the skin is
not so noticeable, the color of the rash
The mottled, blotchy character is seen
most clearly on the chest and the abdomen. It is hj^pergemic and disappears on
pressure, but in the malignant cases it may become of a deep rose, inclining to
purple. Then general symptoms do not abate with the occurrence of the erup-
tion, but persist until the end of the fifth or the sixth day, when they lessen.
Among peculiarities of the rash may be mentioned the development of numer-
ous miliary vesicles and the occurrence of petechia?, which are seen occasionally
even in cases of moderate severity. Recession of the rash, so much dwelt upon
by older writers, is rarely seen. When the '' measles sink in suddenly after they
have begun to come out, and then the patient is seized with anxiety and a
swooning comes on, it is a sign of speedy death" (Rhazes). In reality it is
the failing circulation which causes the rash to fade.
Buccal spots were described by Filatow in 1895, and by Koplik in 1896.
They are seen on a level with the bases of the lower milk molars on either
side, or at the line of junction of the molars when the jaws are closed. They
are white or bluish-white specks, surrounded by red areolae. Their importance
depends upon the fact of their early appearance and remarkable constancy in
the disease — six-sevenths of all cases (Heubner), 97.7 per cent of 214 cases
(Balme).
The fauces may be injected, and there is sometimes an eruption of scat-
tered spots over the entire mucous membrane of the mouth. Ringer was in
the habit of calling attention to opaque white spots on the mucous membrane
of the lips.
Chart IX. — Measles.
not so intense and often less uniform.
MEASLES. 143
Desquamation. — After the rash fades desquamation begins, usually in
the form of fine scales, more rarely in large flakes. It bears a definite rela-
tionship to the extent and intensity of the rash. In mild cases desquamation
may take only a few days, in severe cases several weeks.
The tonsils and the cervical lymph glands may be slightly swollen and
sore; sometimes there is a polyadenitis.
During the course leucocytosis is absent. Its presence generally points
to a complication. Myelocytes are often present in small numbers during the
eruption ( Tiliston ) .
Atypical Measles. — Variations in the course of the disease are not com-
mon. There is an attenuated form, in which the child may be well by the
fourth or fifth day. An abortive form, in which the initial symptoms may be
present, but no eruption appears — morhilli sine morhillis.
Malignant or blade measles is seen most frequently in the wide-spread
epidemics, but it is also met with in institutions, and occasionally in general
practice among children, more rarely in adults. Hemorrhages occur into the
skin and from the mucous membranes; there is very high fever, and all the
features of a profound toxaemia, often with cyanosis, dyspnoea, and extreme
cardiac weakness. Death may occur from the second to the sixth day.
Complications. — Those of the air passages are the most serious. The
coryza may become chronic and lead to irritation of the lymphoid tissues of
the naso-pharynx, leaving enlarged tonsils and adenoids, and not improbably
leaving these parts less able to resist tuberculous invasion. Epistaxis may
sometimes be serious. Laryngitis is not uncommon : the voice becomes husky
and the cough croupy in character. (Edema of the glottis and pseudo-mem-
branous infiammation are rare. Ulceration, abscess, and even perichondritis
may occur.
Bronchitis and Broncho-pneumonia. — In every case of severe measles the
possibility of the existing bronchitis extending to the small tubes and caus-
ing lobular pneumonia has to be considered. It is more apt to occur at the
height of the eruption or as desquamation begins. The high mortality in
institutions is due to this complication, which, as Sydenham remarked, kills
more than the small-pox. (For the s3^mptoms, see the section on the subject.)
Lobar pneumonia is less common.
Severe stomatitis may follow the slight catarrhal form. In institutions
cancrum oris or gangrenous stomatitis is a terrible complication, attacking
sometimes many children. Parotitis occasionally occurs. Intestinal catarrh
and acute colitis are special complications of some epidemics.
Nephritis is less rare than is stated. It is not very uncommon to see cases
of chronic Bright's disease which date from an attack of measles. Vulvitis
may be present as part of the general catarrhal condition.
Endocarditis is rare. Arthritis may follow the fever, or come on at its
height. It may be general and severe. I saw an instance in which anchylosis
of the jaw followed an attack of measles in a child of four years. The con-
junctivitis may be followed by keratitis. Otitis media is not at all uncom-
mon and may lead to perforation of the drum or mastoid disease. Hemiplegia
is a most serious complication. In 4 of my series of 120 cases the hemiplegia
came on during measles. It usually persists. Paraplegia due to acute myelitis
has been described by Barlow, Bruce, and others. Polyneuritis may occur with
144 SPECIFIC INFECTIOUS DISEASES.
wide-spread atrojjliy. Meningitis, abscess of the hrain, and multiple sclerosis
are among the rare comj^lications or sequelae. Whooping-cough not infre-
quently follows measles.
Diagnosis. — During the prevalence of an epidemic the disease is easil}^
recognized. Physicians to isolation hospitals appreciate the practical difficul-
ties. On several occasions I had patients with measles sent to the small-pox
hospital, and it is well to bear in mmd that in adults the beginning of the
eruption on the face, its nodular character, and the isolation of the spots may
be suggestive of variola. From scarlet fever measles is distinguished by the
longer initial stage with characteristic symptoms, and the blotchy irregular
character of the rash, so unlike the diffuse uniform erythema. In measles
the mouth (with the early Koplik sign), in scarlet fever the throat, is chiefly
affected. Occasionally in measles, when the throat is very sore and the erup-
tion pretty diffuse, there may at first be difficulty in determining which dis-
ease is present, but a few days should suffice to make the diagnosis clear. As
a rule there is no leucocytosis. It may be extremely difficult to distinguish
from rotheln. I have more than once known practitioners of large experience
unable to agree upon a diagnosis. The shorter prodromal stage, the absence
of oculo-nasal catarrh, and the slighter fever in many cases, are perhaps the
most important features. It is difficult to speak definitely about the distinc-
tions in the rash, though perhaps the more uniform distribution and the
absence of the crescentic arrangement are more constant in rotheln. In Afri-
cans the disease is easily recognized; the papules stand out with great plain-
ness, often in groups; the hypersemia is to be seen on all but the very black
skins. The distribution of the rash, the coryza, and the rash in the mouth
are important points. The conditions under which measles may be mistaken
for small-pox have already been described. Of drug eruptions, that induced
by copaiba is very like measles, but is readily distinguished by the absence of
fever and catarrh. Antipyrin, chloral, and quinine rashes rarely cause any
difficulty in diagnosis. The serum exanthem of the diphtheria antitoxin may
be difficult to recognize. In adults the acute malignant measles may resemble
typhus fever. Occasionally erythema multiforme may simulate measles.
Prophylaxis. — The difficulty is inherent in the prolonged incubation and
the four days of invasion, during which the catarrhal symptoms are marked,
and in which the disease is probably contagious, and one often finds that the
quarantine which has been carried out so efficiently has been in vain. From
contact with cases in the stage of invasion and mild cases with scarcely any
fever the disease is readily disseminated through schools and conveyed to
healthy children in the every-day contact with each other on the streets, in
the squares and play-grounds. Once manifested, the child should be carefully
quarantined and all possible precautions taken against the spread of the dis-
ease in the house. As the germ of measles seems to have a feeble vitality the
quarantine need not.be so protracted as in scarlet fever.
Prognosis. — Among the eruptive fevers measles ranks third in the death-
rate. The mortality from the disease itself is not high, but the pulmonary
complications render it one of the most serious of the diseases of children.
In some epidemics, particularly in institutions and in armies, the death-rate
may be high, not so much from the fever itself as from the extension of the
catarrhal sjonptoms to the finer bronchial tubes. Imported in 1875 from
RUBELLA. 145
Sydney by H.M.S. Dido to the Fiji Islands, 40,000 out of 150,000 of the
inhabitants died in four months. Panum, tlie distinguished Danish physician,
described the wide-spread and fatal epidemic which decimated the inhabitants
of the Faroe Islands in 1846. In private practice the mortality is from 2 to
3 per cent; in hospitals from 6 to 8 or 10 per cent.
Treatment. — Confinement to bed in a well- ventilated room and a light
diet are the only measures necessary in cases of uncomplicated measles. The
fever rarely reaches a dangerous height. If it does it may be lowered by
sponging or by the tepid bath gradually reduced. If the rash does not come
out well, warm drinks and a hot bath will hasten its maturation. The bowels
should be freely opened. If the cough is distressing, paregoric and a mixture
of ipecacuanha wine and squills should be given. The patient should be kept
in bed for a few days after the fever subsides. During desquamation the skin
should be oiled daily, and warm baths given to facilitate the process. The
mouth and nostrils should be carefully cleansed, even in mild cases. The
convalescence from measles is the most important stage of the disease. Watch-
fulness and care may prevent serious pulmonary complications. The frequency
with which the mothers of children with simple or tuberculous broncho-pneu-
monia tell us that " the child caught cold after measles," and the contempla-
tion of the mortality bills, should make us extremely careful in our manage-
ment of this affection.
IX. RUBELLA (Rotheln. German Measles).
This exanthem has also the names of rubeola notha, or epidemic roseola,
and, as it is supposed to present features common to both, has been also known
as hybrid measles or hybrid scarlet fever. It is now generally regarded, how-
ever, as a separate and distinct affection.
Etiology. — It is propagated by contagion and spreads with great rapidity.
It frequently attacks adults, and the occurrence of either measles or scarlet
fever in childhood is no protection against it. The epidemics of it are often
very extensive.
Symptoms. — These are usually mild, and it is altogether a less serious
affection than measles. Very exceptionally, as in the epidemics studied by
Cheadle, the symptoms are severe.
The stage of incubation is two weeks or even longer.
In the stage of invasion there are chilliness, headache, pains in the back
and legs, and coryza. A macular, rose-red eruption on the throat is a constant
symptom, and, indeed, it was on this account that it was originally regarded
as a hybrid, having the sore throat of scarlet fever and the rash of measles.
There may be very slight fever. In 30 per cent of Edwards's cases the tem-
perature did not rise above 100°. The duration of this stage is somewhat
variable. The rash usually appears on the first day, some writers say on the
second, and others again give the duration of the stage of invasion as three
days. Griffith places it at two days. The eruption comes out first on the
face, then on the chest, and gradually extends so that within twenty-four
hours it is scattered over the whole body. It may be the first symptom noted
by the mother. The eruption consists of a number of round or oval, slightly
raised spots, pinkish-red in color, usually discrete, but sometimes confluent.
11
146 SPECIFIC INFECTIOUS DISEASES.
The color of the rash is somewhat brighter than in measles. The patches
are less distinctly crescentic. After persisting for two or three days (some-
times longer), it gradually fades and there is a slight furfnraceous desquama-
tion. The rash persists as. a rule longer than in scarlet fever or measles, and
the skin is slightly stained after it. In some cases the rash is scarlatiniform,
which may even follow a measly eruption. The Ijonphatic glands of the
neck are frequently swollen, and, when the eruption is very intense and dif-
fuse, the lymph-glands in the other parts of the body.
There are no special complications. The disease usually progresses favor-
ably; but in rare instances, as in those reported by Cheadle, the s}miptoms are
of greater severity. Albuminuria, arthritis, or even nephritis may occur.
Pneumonia and colitis have been present in some epidemics. Icterus has
been seen.
Diagnosis. — The slightness of the prodromal s3T.nptoms, the mildness, or
the absence of the fever, the more diffuse character of the rash, its rose-red
color, and the early enlargement of the cervical glands, are the chief points of
distinction between rotheln and measles.
The treatment is that of a simple febrile affection.
" Fourth Disease." — Clement Dukes, in a paper on the confusion of two
different diseases under the name rubella, describes what he calls a " fourth
disease," in which the body is covered in a few hours with a diffuse exanthem
of a bright red color, almost scarlatiniform in appearance. The face may
remain quite free. The desquamation is more marked than in rotheln.
Erythema Infectiosum. — Under this term there has been described of late
years in Germany, particularly by Escherich, a feebly contagious disease, char-
acterized by a rose-red, maculo-papular rash, appearing chiefly between the
ages of four and twelve. It has occurred in epidemic form in the spring and
summer. It has followed outbreaks of measles or of rotheln. The most char-
acteristic feature is the morbilliform eruption on the extremities, chiefly on
the extensor surfaces. The trunk as a rule remains free.
X. EPIDEMIC PAROTITIS (Mumps).
Definition. — A specific infectious disease, characterized by swelling" of the
salivary glands and a special liability to orchitis.
Hippocrates described the disease and its peculiarities — an affection of
children and young male adults, the absence of suppuration, and the orchitis.
Etiology. — The nature of the virus is unknown.
It is endemic in large centres of population, and at certain seasons, par-
ticularly spring and autumn, the cases increase rapidly. It is met most fre-
quently in childhood and adolescence. Very young infants and adults are
seldom attacked. Males are somewhat more frequently affected than females.
In institutions, barracks, and schools the disease has been known to attack
over 90 per cent of the residents. It may be curiously localized in a city or
district, or even in one part of a school or barrack. The disease is contagious
and spreads from patient to patient. The infection may persist for as long as
six weeks. It may be congenital, and Hale White has reported a case in which
the mother and her new-born child were attacked at the same time.
EPIDEMIC PAROTITIS, 147
A remarkable idiopathic, non-specific parotitis may follow injury or dis-
ease of the abdominal or pelvic organs (see Diseases of the Salivary Glands),
Symptoms. — The period of incubation is from two to three weeks, and there
are rarely any symptoms during this stage. The invasion is marked by fever,
which is usually slight, rarely rising above 101°, but in exceptionally severe
cases going up to 103° or 104°. The child complains of pain just below the
ear on one side. Here a slight swelling is noticed, which increases gradually,
until, within forty-eight hours, there is great enlargement of the neck and
side of the cheek. The swelling passes forward in front of the ear, the lobe
of which is lifted, and back beneath the sterno-mastoid muscle. The other
side usually becomes affected within a day or two, and the whole neck is sur-
rounded by a collar of doughy infiltration. Only one gland may be involved,
or an interval of four or five days may elapse before the other side is involved.
The submaxillary and sublingual glands become swollen, though not always;
in a few cases they may be alone attacked. The lachrymal glands may be
involved. The greatest inconvenience is experienced in taking food, for the
patient is unable to open the mouth, and even speech and deglutition become
difficult. There may be an increase in the secretion of the saliva, but the
reverse is sometimes the case. The mucous membrane of the mouth and throat
may be slightly inflamed. There is seldom great pain, but an unpleasant feel-
ing of tension and tightness. There may be earache, even otitis media, and
slight impairment of hearing.
After persisting for from seven to ten days, the swelling gradually sub-
sides and the child rapidly regains his strength and health and is none the
worse for the attack.
Occasionally the disease is very severe and characterized by high fever,
delirium, and great prostration. The patient may even lapse into a typhoid
condition.
Eelapse is rare, but there may be within a few weeks two or three slight
recurrences, in which I have known the cervical glands to enlarge. A second
or even a third attack may occur.
Orchitis. — Excessively rare before puberty, it occurs usually about the
eighth day, and more particularly if the boy is allowed to leave his bed
(Dukes), One or both testicles may be involved. The swelling may be great,
and occasionally effusion takes place into the tunica vaginalis. The orchitis
may occur before the parotitis, or in rare instances may be the only mani-
festation of the infection (orchitis parotidea). The inflammation increases
for three or four days, and resolution takes place gradually. There may be
a muco-purulent discharge from the urethra. In severe cases atrophy may
follow, fortunately as a rule only in one organ; occurring in both before
puberty the natural development is usually checked. Even when both testicles
are atrophied and small, sexual vigor may be retained. The proportion of
cases of orchitis varies in different epidemics; 211 cases occurred in 699 cases,
and 103 cases of atrophy followed 163 instances of orchitis (Comby). JSTo
satisfactory explanation of this remarkable metastasis has been given. Mili-
tary, surgeons, who see so much of the disease in young recruits, have sug-
gested the transference of the virus to the penis with the fingers and its trans-
mission along the urethra.
A vulvo-vaginitis sometimes occurs in girls, and the breasts may become
148 SPECIFIC INFECTIOUS DISEASES.
enlarged and tender. Mastitis has been seen in boys. Involvement of the
ovaries is rare. The thyroid gland may enlarge in the attack, and there have
been features suggestive of acute pancreatitis.
Complications and Sequelae. — Of these the cerebral affections are jDcrhaps
the most serious. As already mentioned, there may be delirium and high
fever. In rare instances meningitis has been found. Hemiplegia and coma
may also occur. A majority of the fatal cases are associated with meningeal
symptoms. These, of course, are very rare in comparison with the frequency
of the disease; 3'et, in the Index Catalogue, under this caption, there are six
fatal cases mentioned. In some epidemics the cerebral complications are much
more marked than in others. Acute mania has occurred, and there are in-
stances on record of insanity following the disease.
Arthritis, albuminuria, even acute uraemia with convulsions, endocarditis,
pleurisy, facial paralysis, hemiplegia, and peripheral neuritis are occasional
complications.
Suppuration of the gland is an extremely rare complication. Gangrene
has occasionally occurred. The special senses may be seriously involved.
Deafness may occur, and may be permanent. Affections of the eye are rare,
but optic neuritis with atrophy has been described.
Chronic hj^pertrophy of the gland may follow.
The diagnosis of the disease is usually easy. The position of the swelling
in front of and below the ear and the elevation of the lobe on the affected side
definitely fix the locality of the swelling. In children inflammation of the
parotid, apart from ordinary mumps, is excessively rare.
Treatment. — It is well to keep the patient in bed during the height of the
disease. The bowels should be freely opened, and the patient given a light
liquid diet. E'o medicine is required unless the fever is high, in which case
aconite may be given. Cold compresses may be placed on the gland, but chil-
dren, as a rule, prefer hot applications. A pad of cotton wadding covered with
oil silk is the best application. Suppuration is hardly ever to be dreaded, even
though the gland become very tense. Should redness and tenderness develop,
leeches may be used. With delirium and head symptoms the ice-cap may be
applied. For the orchitis, rest, with support and protection of the swollen
gland with cotton-wool, is usually sufficient.
XI. WHOOPING-COUGH.
Definition. — A specific affection characterized by catarrh of the respiratory
passages and a series of convulsive coughs which end in a long-drawn inspira-
tion or "whoop."
History. — Ballonius, in his Ephemerides, describes the disease as it ap-
peared in 1578. Glisson and Sj^denham in the following century gave brief
accounts. Willis (Pharmaceutice Eationalis, second part, 1674) gave a much
better description and called it an " epidemical disorder."
Etiology. — The disease occurs in epidemic form, but sporadic cases appear
in a community from time to time. It is directly contagious from person to
person; but dwelling-rooms, houses, school-rooms, and other localities may be
infected by a sick child. It is, however, in this way less contagious than other
WHOOPING-COUGH. 149
diseases, and is probably most often taken by direct contact. Epidemics pre-
vail for two or three months, usually during the winter and spring, and have
a curious relation to other diseases, often preceding or following epidemics of
measles, less frequently of scarlet fever.
Children between the first and second dentitions are most liable to be
attacked. Sucklings are, however, not exempt, and I have seen very severe
attacks in infants under six weeks. Congenital cases are described. It is
stated that girls are more subject to the disease than boys. Adults and old
people are sometimes attacked, and in the aged it may be a very serious affec-
tion. It appears to be most contagious in the catarrhal period. A natural
immunity has been mentioned, but it must be remembered that a child may
have the disease in a very mild form. As a rule, one attack protects; second
attacks are excessively rare. Delicate anaemic children with nasal or bronchial
catarrh are more subject to the disease than others. According to the United
States Census Eeports, the disease is more than twice as fatal in the negro
race than in others.
Czaplewski, Koplik, and Hensel describe a small bacillus with rounded
ends. A serum even has been prepared. More recently Bordet has described
a special germ, and Fraenkel a small ovoid bacterium. The influenza bacillus
has been found in some cases.
Morbid Anatomy. — Whooping-cough' itself has no special pathological
changes. In fatal cases pulmonary complications, particularly broncho-pneu-
monia, are usually present. Collapse and compensatory emphysema, vesicular
and interstitial, are found, and the tracheal and bronchial glands are enlarged.
Symptoms. — There is a variable period of incubation of from seven to ten
days. Catarrhal and paroxysmal stages can be recognized. In the catarrhal
stage the child has the symptoms of an ordinary cold, which may begin with
slight fever, running at the nose, injection of the eyes, and a bronchial cough,
usually dry, and sometimes giving indications of a spasmodic character.
Trousseau calls attention to the incessant character of the early cough. The
fever is usually not high, and slight attention is paid to the symptoms, which
are thought to be those of a simple catarrh. After lasting for a week or ten
days, instead of subsiding, the cough becomes worse and more convulsive in
character.
The paroxysmal stage, marked by the characteristic cough, dates from the
first appearance of the " whoop." The fit begins with a series of from fifteen
to twenty forcible short coughs of increasing intensity, between which no
inspiratory effort is made. The child gets blue in the face, and then with a
deep inspiration the air is drawn into the lungs, making the " whoop,^' which
may be heard at a distance, and from which the disease takes its name. A
deep inspiration may precede the series of spasmodic expiratory efforts. Sev-
eral coughing-fits may succeed each other until a tenacious mucus is ejected,
usually small in amount, but after a series of coughing-fits a considerable
quantity may be expectorated. Vomiting often takes place at the end of a par-
oxysm, and may recur so frequently in the day that the child does not get
enough food and becomes emaciated. There may be only four or five attacks in
the day, or in severe cases they may recur every half -hour. In severe and fatal
cases the paroxysms may exceed one hundred daily. During the paroxysm
the thorax is very strongly compressed by the powerful expiratory efforts, and.
150 SPECIFIC INFECTIOUS DISEASES.
as very little air passes in through the glottis, there are signs of defective
aeration of the blood ; the face Ijecomes SAVollen and congested, the veins are
prominent, the e3^eballs protrude, and the conjunctivae become deeply engorged.
Suffocation indeed seems imminent, when with a deep, crowing inspiration air
enters the lungs and the color is quickly restored. The child knows for a
few moments when the attack is coming on, and tries in every way to check
it, but failing to do so, runs terrified to the nurse or mother to be supported,
or clutches anything near by. Few diseases are more painful to witness. In
severe paroxysms the sphincters may be opened. The urine is said to be of
high specific gravity (1022-1032), pale 3'ellow, and to contain much uric acid.
An ulcer may form under the tongue from rubbing on the teeth (Riga's
disease).
During the attack, if the chest be examined, the resonance is defective in
the expiratory stage, full and clear during the deep, crowing insj^iration ; but
on auscultation during the latter there may be no vesicular murmur heard,
owing to the slowness with which the air passes the narrowed glottis. Bron-
chial rales are occasionally heard.
Among circumstances which precipitate a paroxysm are emotion, such as
crying, and any irritation about the throat. Even the act of swallowing some-
times seems sufficient. In a close dusty atmosphere the coughing-fits are more
frequent. After lasting for three or four weeks the attacks become lighter
and finalh' cease. In cases of ordinary severity the course of the disease is
rarel}' under six weeks.
The complications and sequelae of whooping-cough are important. During
the extensive venous congestion hgemorrhages are very apt to occur in the
form of petechige, particularly about the forehead, ecchymosis of the conjunc-
tivge, and even bleeding tears of blood (Trousseau) from the rupture of the
vessels, epistaxis, bleeding from the ears, and occasionally hemoptysis.
Hsemorrhage from the bowels is rare. Convulsions are not very uncommon,
due perhaps to the extreme engorgement of the cerebral cortex. Death has
occurred from spasm of the glottis. Sudden death has been caused by exten-
sive subdural hemorrhage. Paralysis is a rare event. It was associated with
3 of my series of 120 cases, but in none of them did the hemiplegia come on
during the paroxysm, as in a case reported by S. West. Valentine (1901) has
collected 79 cases, chiefly hemiplegias. A spastic paraplegia may follow.
Acute pohnieuritis is a rare sequel.
The persistent vomiting may induce marked angemia and wasting. The
pulmonary complications are extremely serious. During the severe coughing-
spells interstitial emphysema may be induced, more rarely pneumothorax. I
saw one instance in which rupture occurred, evidently near the root of the
lung, and the air passed along the trachea and reached the subcutaneous tis-
sues of the neck, a condition which has been knoAvn to become general.
Capillary bronchitis, lobular and pseudo-lobar pneumonia are the dangerous
complications, responsible for nine out of ten deaths in the disease. In some
cases the process is tuberculous. Pleurisy is sometimes met with and occa-
sionally lobar pneumonia. Enlargement of the bronchial glands is very com-
mon in whooping-cough, and has been thought to cause the disease. It may
sometimes be sufficient to produce dulness over the manubrium. During the
spasm the radial pulse is small, the right heart engorged, and during and
I
WHOOPING-COUGH. 151
after the attack the cardiac action is very much disturbed. Serious damage
may result, and possibly some of the cases of severe valvular disease in chil-
dren who have had neither rheumatism nor scarlet fever may be attributed
to the terrible heart strain during a prolonged attack. Koplik regards the
swelling about the face and eyes as an important sign of the heart strain.
Serious renal complications are very uncommon, but albumin sometimes and
sugar frequently are found in the urine. A distressing sequel in adults is
asthma, which may recur at intervals for a year or more. An unusually
marked leucocytosis appears early, chiefly of the lymphocytes (Meunier).
Diagnosis. — So distinctive is the " whoop " of the disease that the diag-
nosis is very easy; but occasionally there are doubtful cases, particularly dur-
ing epidemics, in which a series of expiratory coughs occurs without any
inspiratory crow.
Prognosis. — If we include its complications, whooping-cough is a very fatal
affection, ranking first among the acute infections as a cause of death in chil-
dren under five years of age. It exceeds diphtheria and scarlet fever in gross
mortality. In 1903 there were 9,522 deaths in England and Wales, 97 per
cent in children under five years of age (Tatham). The disease should be
placed on the list of reportable infections. As it is highly probable that the
contagion persists for a very long time, special care should be taken in the
inspection of school children during their convalescence.
Treatment. — The gravity of the disease is scarcely appreciated by the pub-
lic. Children with the disease should not be sent to school or exposed in
public in any way. There is more reprehensible neglect in connection with
this than with any other disease. The patient should be isolated, and if
the paroxysms are at all severe, at rest in bed. Fresh air, night and day,
is important, but in cities in the winter this is not easy to manage. The
treatment is notoriously unsatisfactory. If asked the two most important
things, I should say, six weeks and a good big bottle of paregoric. Antiseptic
measures have been extensively tried. Quinine holds its own with many -prac-
titioners; a sixth of a grain may be given three times a day for each month
of age, and a grain and a half for each year in children under five. A one-
per-cent solution of resorcin swabbed on the throat, two or three grains of
iodoform to an ounce of starch powder, insufflated, and the carbolic-acid spray
may be tried. For the catarrhal symptoms moderate doses of ipecac are prob-
ably the most satisfactory. Sedatives are by far the most trustworthy drugs
in severe cases, and paregoric may be given freely, particularly to give rest at
night. Jacobi advises belladonna in full doses, as much as one-sixth of a
grain of the extract to a child of six or eight months three times a day.
Other remedies, such as antipyrin, bromin, and bromoform, may be tried.
In older children and in adults it would be worth while, I think, to try the
intratracheal injections of olive-oil and iodoform, which are sometimes so
useful in allaying severe paroxysmal cough. It is impossible to mention all
the drugs which have been recommended, numbering nearly fifty in a recent
system of medicine.
After the severity of the attack has passed and convalescence has begun,
the child should be watched with the greatest care. It is just at this period
that the fatal broncho-pneumonias are apt to develop. The cough sometimes
persists for months and the child remains weak and delicate. Change of air
152 SPECIFIC INFECTIOUS DISEASES.
should be tried. Sucli a patient should be fed with care, and given tonics and
cod-liver oil.
XII. INFLUENZA (La Grippe).
Definition. — A pandemic disease, appearing at irregular intervals, char-
acterized by extraordinary rapidity of extension and the large number of peo-
ple attacked. Following the pandemic there are, as a rule, for several years
endemic, epidemic, or sporadic outbreaks in different regions. Clinically, the
disease has protean aspects, but a special tendency to attack the respiratory
mucous membranes.
History. — Great pandemics have been recognized since the sixteenth cen-
tury. There were four with their succeeding epidemics during the last cen-
tury—1830-33, 1836-'37, 1847-48, and 1889-90. The last pandemic seems
to have begun, as many others had before, in the far East. It may have started
in May, 1889, in Buchara, reaching Moscow in September, the Caucasus and
St. Petersburg in October. By the middle of November Berlin was attacked.
By the middle of December it was in London, and by the end of the month
it had invaded New York, and was widely distributed over the entire con-
tinent. Within a year it had visited nearlj'' all parts of the earth.
The duration of an epidemic in any one locality is from six to eight weeks.
With the exception, perhaps, of dengue, there is no disease which attacks in-
discriminately so large a proj)ortion of the inhabitants, about 40 per cent as
a rule. Fortunately, as in dengue, the rate of mortality is very low. Of
55,263 cases reported in the German army, 60 died, or about 0.1 per cent.
As might be expected, in the civil population the mortality is somewhat higher,
reaching 133, or about 0.5 per cent of the 32,973 cases reported in Munich.
Over one-half of these deaths were due to pneumonia. In 1903 the deaths in
England and Wales numbered 6,333. There has been a gradual diminution
of the death-rate from this disease • during the past three years (Tatham).
The opportunity for studying the disease in the last epidemic has thrown much
light upon many problems. Among the most notable productions were the
work of Pfeiffer on the etiology of the disease, the elaborate Berlin report by
von Leyden and Senator, and the Local Government Board's report by Par-
sons. Leichtenstern's article in Nothnagel's Handbuch is the most masterly
and systematic consideration of the disease in the literature.
Etiolog-y. — What relation has the epidemic influenza to the ordinary influ-
enza cold or catarrhal fever (commonly also called the grippe), which is con-
stantly present in the community? Leichtenstern answers this question l)y
making the following divisions: (1) Epidemic influenza vera, caused by
Pfeiffer's bacillus; (3) endemic-epidemic influenza vera, which often occurs
for several years in succession after a pandemic, also caused by the same
bacillus; (3) endemic influenza nostras, pseudo-influenza or catarrhal fever,
commonly called the grippe, which is a special disease, still of unknovni etiol-
ogy, and which bears the same relation to the true influenza as cholera nostras
does to Asiatic cholera.
Since the last pandemic we have not been free from local outbreaks in
some part of the world. In some places the disease seems to have been con-
tinually present.
INFLUENZA. 153
Euhemann reports 1,979 cases of typical grippe between 1895 and 1903.
In 115 he demonstrated the influenza bacillus. Lord (in Boston) demonstrated
influenza bacilli in about 30 per cent of 100 unselected cases of acute and
chronic bronchitis. Yet during this period there was no epidemic of influenza
in the city. The reports are sufficiently numerous to show that the influenza
bacillus is probably constantly with us. Many observations show that it is a
frequent invader of the respiratory tract in the inter-epidemic periods and is
probably responsible for many of the cases of Leichtenstern's influenza nostras.
Indeed, it seems to bear a similar relation to the acute infections of the
respiratory tract as other common organisms. It is still unexplained why it
should stand in a different relation to the epidemics of influenza as the sole
cause of the disease.
The disease is highly contagious; it spreads with remarkable rapidity,
which, however, is not greater than modern methods of conveyance. In the
great pandemic of 1889-'90 some of the large prisons escaped entirely. The
outbreak of epidemics is independent of all seasonal and meteorological con-
ditions, except perhaps sunshine. The worst have been in the colder seasons
of the year. One attack does not necessarily protect from a subsequent one.
A few persons appear not to be liable to the disease.
Bacteriology. — In 1892 Pfeiffer isolated a bacillus from the nasal and
bronchial secretions, which is recognized as the cause of the disease. It is a
small, non-motile organism, which stains well in Loefiler's methylene blue, or
in a dilute, pale-red solution of carbol-fuchsin in water. On culture media
it grows only in the presence of haemoglobin. In the presence of contaminat-
ing organisms, especially the staphylococcus aureus, the growth of influenza
colonies is particularly luxuriant. The organism is probably frequently over-
looked in mixed cultures because of failure to recognize the character of these
colonies in symbiosis. The bacilli are present in enormous numbers in the
nasal and bronchial secretions of patients, in the latter almost in pure cultures.
They persist often after the severe symptoms have subsided.
The much-discussed question whether during the presence of an epidemic
human influenza attacks animals must be answered in the negative. In great
pandemics of influenza the general rule seems to hold that other diseases do
not prevail to the same extent, but it may be that other diseases are wrongly
included under influenza.
Symptoms. — The incubation period is " from one to four days ; of tenest
three to four days." The onset is usually abrupt, with fever and its associated
phenomena.
Types of the Disease. — The manifestations are so extraordinarily complex
that it is best to describe them under types of the disease.
1. Eespiratory. — The mucous membrane of the respiratory tract from
the nose to the air-cells of the lungs may be regarded as the seat of election
of the influenza bacilli. In the simple forms the disease sets in with coryza,,
and presents the features of an acute catarrhal fever, with perhaps rather
more prostration and debility than is usual. In other cases after catarrhal
symptoms broncnitis occurs, the iever"^increases, there is delirium and much
prostration, and the picture may even be that of severe typhoid fever._ The
graver respiratory conditions are bronchitis, pleurisy, and pneumonia — The,
bronchitis has really no special peculiarities. 'I'he sputum is^pposed by
154 SPECIFIC INFECTIOUS DISEASES.
man}' to be distinctive. Sometimes it is in extraordinary amounts, very thin,
and containing purulent masses. Pfeilt'er regards sputum of a greenish-yellow
color and m coin-like lumprf atj almost characteristic oi mduenza. In other"
cases there rday b5 a dark rea. bloody sputum. One of the most "distressing _
sequels of the influenza bronchitis is diffuse bronchiectasis, of vrhich I have
seen several instances. It occasionally happens that the bronchitis is of greats
i-nfPTigify flnrl rpflpbps; Ibp finer tnbes, SO that the patient becomes cyanosed or
even asphyxiated.
/-Influenza pneumonia is one of the most serious manifestations, and may
depend wpon Pfeiffer's bacillus itself, or is the result of a mixed infection.
The true influenza pneumonia is most commonly lobular or catarrhal, prob-
ably never croupous. Much of the mortality of the disease depends upon the
fatal character of this complication. The clinical course of the cases is often
irregular and the s3'mptoms are obscure or masked.
Influenza pleurisy is more rare, but cases of primary involvement of the
pleura are reported. It is very apt to lead to empyema. Pulmonary tubercu-
losis is usually much aggravated by an attack of influenza.
2. Nervous Form. — Without any catarrhal sj^mptoms there are severe
headache, pain in the back and joints, with profound prostration. Among the
more serious complications may be mentioned meningitis and encephalitis, the
latter leading to hemiplegia or monoplegia. Abscess of the brain has followed
in acute cases. Myelitis, with symptoms like an acute Landry's paralysis, has
occurred, and spastic paraplegia or a pseudo-tabes may follow an attack.
The influenza bacillus has been demonstrated by lumbar puncture during
life and in the meninges after death. . All forms of neuritis are not uncom-
mon, and in some cases are characterized by marked disturbance of motion
and sensation. Judging from the accounts in the literature, almost every
form of disease of the nervous system may follow influenza.
Among the most important of the nervous sequelge are depression of spirits,
melancholia, and in some cases dementia.
3. Gastro-ixtestinal Form. — "With the onset of the fever there may be
nausea and vomiting, or the attack may set in with abdominal pain, profuse
diarrhoea, and collapse. In some epidemics jaundice has been a common
symptom. In a considerable number of the cases there is enlargement of the
spleen, depending chiefly upon the intensity of the fever. This was a very
rare form in the United States.
4. Febrile Form. — The fever in influenza is very variable, but it is im-
portant to recognize that it may be the only manifestation of the disease. It
is sometimes markedly remittent, with chills; or in rare cases there is a pro-
tracted, continued fever of several weeks' duration, which simulates typhoid
closely (W. W. Johnston).
Complications. — The pericarditis is apt to be latent. Of endocarditis, a
number of cases have been reported. There have been at least three caees
at the Johns Hopkins Hospital in which micro-organisms morphologically
like influenza bacilli have been isolated from the vegetations (Mabel Austin).
The malignant form may occur. Myocarditis may follow, and has been a
cause of sudden death. Functional disturbances are common, palpitation,
bradycardia, tachycardia, and angina-like attacks. Phlebitis and thrombosis
of various vessels have been described.
INFLUENZA. ■ 155
Septiccemia was demonstrated in four of eight cases by Meunier in the
cultivation of influenza bacilli from the circulating blood.
Peritonitis is rare. There have been a few cases published, only one, so far
as I know, by Hill and Fisch, in which the bacillus was demonstrated in the
exudate.
Cholelithiasis may follow an attack. Influenza bacilli were demonstrated
in pure culture in the pus from the gall-bladder by Heyroosky.
The increased prevalence of appendicitis has been attributed to influenza.
Various renal affections have been noted. G. Baumgarten has called atten-
tion to the frequency of nephritis. Orchitis has been also seen. Herpes is
common. A difl^use erythema sometimes occurs, occasionally purpura. Ca-
tarrhal conjunctivitis is a frequent event. Iritis, and in rare instances optic
neuritis, have been met with. Acute otitis media is a common complication.
I have seen severe and persistent vertigo follow influenza, probably from
involvement of the labyrinth. Bronchiectasis may follow. I have seen sev-
eral cases; in a recent fatal one of three years' duration the bacilli were pres-
ent in the sputa.
Since the late severe epidemics it has been the fashion to date various
ailments or chronic ill-health from influenza. In many cases this is correct.
It is astonishing the number of people who have been crippled in health for
years after an attack.
Diagnosis. — During a pandemic the cases offer but slight difflculty. The
profoundness of the prostration, out of all proportion to the intensity of the
disease, is one of the most characteristic features. In the respiratory form
the diagnosis may be made by the bacteriological examination of the sputum,
a procedure which should be resorted to early in a suspected epidemic. The
differentiation of the various forms has been already sufficiently considered.
Treatment. — Isolation should be practised when possible, and old people
should be guarded against all possible sources of infection. The secretions,
nasal and bronchial, should be thoroughly disinfected. In every case the
disease should be regarded as serious, and the patient should be confined to
bed until the fever has completely disappeared. In this way alone can serious
complications be avoided. From the outset the treatment should be support-
ing, and the patient should be carefully fed and well nursed. The bowels
should be opened by a dose of calomel or a saline draught. At night 10 grains
of Dover's powder may be given. At the onset a warm bath is sometimes
grateful in relieving the pain in the back and limbs, but great care should be
taken to have the bed well warmed, and the patient should be given after it
a drink of hot lemonade. If the fever is high and there is delirium, small
doses of antipyrin may be given and an ice-cap applied to the head. The
medicinal antipyretics should be used with caution, as profound prostration
sometimes occurs after their employment. Too much stress should not be
laid upon the mental features. Delirium may be marked even with slight
fever. In the cases with great cardiac weakness stimulants should be given
freely, and during convalescence strychnia in full doses.
The intense bronchitis, pneumonia, and other complications should re-
ceive their appropriate treatment. The convalescence requires careful man-
agement, and it may be weeks or months before the patient is restored to full
health. A good nutritious diet, change of air, and pleasant surroundings are
156 SPECIFIC INFECTIOUS DISEASES.
essential. The depression of spirits following this disease is one of its most
unpleasant and obstinate features.
XIII. DENGUE.
Definition. — An acute infectious disease of tropical and subtropical re-
gions, characterized by febrile paroxysms, pains in the joints and muscles, an
initial erythematous, and a terminal polymorphous eruption.
It is knoT\Ti as treah-hone fever from the atrocious character of the pain,
and dandy fever from the stiff, dandified gait. The word dengue is sup-
posed to be derived from a Si)anish, or j)ossibly Hindostanee, equivalent of
the word dandy.
History and Geographical Distribution. — The disease was first recognized
in 1779 in Cairo and in Java, where Brylon described the outbreak in Batavia.
The description by Benjamin Eush of the epidemic in Philadelphia in 1780
is one of the first and one of the very best accounts of the disease. Between
1821 and 1828 it was ^^revalent at intervals in India and in the Southern
States. S. H. Dickson gives a graphic description of the disease as it appeared
in Charleston in 1828. Since that date there have been four or five wide-
spread epidemics in tropical countries and on this continent along the Gulf
States, the last in the summer of 1897. None of the recent epidemics have
extended into the Northern States, but in 1888 it prevailed as far north as
Virginia. It has prevailed in the Philippine Islands among the United States
troops and among the natives.
Etiology. — The rapidity of diffusion and the pandemic character are the
two most important features of dengue. There is no disease, not even influ-
enza, which attacks so large a proportion of the population. In Galveston, in
1897, 20,000 people were attacked within two months. Ashburn and Craig
have shown that it is transmitted by the bite of a mosquito, Culex fatigans.
The specific germ is still undetermined, but is probably ultramicroscopic.
As the disease is rarely fatal, no observations have been made upon its
pathological anatomy.
Symptoms. — The period of incubation is from three to five daj^s, during
which the patient feels well. The attack sets in suddenly with headache, chilly
feelings, and intense aching pains in the joints and muscles. The tempera-
ture rises graduall}^, and may reach 106° or 107°. The pulse is rapid, and
there are the other phenomena associated with acute fever — ^loss of appetite,
coated tongue, slight nocturnal delirium, and concentrated urine. The face
has a suffused, bloated appearance, the eyes are injected, and the visible mu-
cous membranes are flushed. There is a congested, erythematous state of the
skin. Eush's description of the pains is worth quoting, as in it the epithet
break-bone occurs in the literature for the first time. " The pains which
accompanied this fever were exquisitely severe in the head, back, and limbs.
The pains in the head were sometimes in the back parts of it, and at other
times they occupied only the eyeballs. In some people the pains were so acute
in their backs and hips that they could not lie in bed. In others, the pains
affected the neck and arms, so as to produce in one instance a difficulty of
moving the fingers of the right hand. They all complained more or less of a
soreness in the seats of these pains, particularly when they occupied the head
CEREBROSPINAL FEVER. 157
and eyeballs. A few complained of their flesh being sore to the touch in every
part of the body. From these circumstances the disease was sometimes be-
lieved to be a rheumatism, but its more general name among all classes of
people was the break-bone fever." The large and small joints are affected^
sometimes in succession, and become swollen, red, and painful. In some cases
cutaneous hypersesthesia has been noted. Haemorrhage from the mucous mem-
branes was noted by Kush, Black vomit has also been described by several
observers.
The fever gradually reaches its maximum by the third or fourth day; the
patient then enters upon the apyretic period, which may last from two to
four days, and in which he feels prostrated and stiff. A second paroxysm
of fever then occurs, and the pains return. In a large number of cases an
eruption is common, which, judging from the description, has nothing dis-
tinctive, being sometimes macular, like that of measles, sometimes diffuse and
scarlatiniform, or papular, or lichen-like. In other instances the rash has
been described as urticarial, or even vesicular. The rash may persist for a
month after the symptoms have disappeared (Woolley). Certain writers de-
scribe inflammation and hyperaamia of the mucous membrane of the nose,
mouth, and pharynx. Enlargement of the lymph-glands is not uncommon,
and may persist for weeks after the disappearance of the fever. Convalescence
is often protracted, and there is a degree of mental and physical prostration
out of all proportion to the severity of the primary attack. The pains in
the joints or muscles, sometimes very local, may persist for weeks. Rush
refers to the former, stating that a young lady after recovery said it should
be called break-heart, not break-bone, fever. The average duration of a mod-
erate attack is from seven to eight days. Dengue is very seldom fatal. Dick-
son saw three deaths in the Charleston epidemic.
Complications are rare. Insomnia and occasionally delirium, resembling
somewhat the alcoholic form, have been observed, and convulsions in children.
Atrophy of the muscles may occur after the attack (Woolley). A relapse may
occur even as late as two weeks.
Diagnosis. — The diagnosis of the disease, prevailing, as it does in epidemic
form and attacking all classes indiscriminately, rarely offers any special diffi-
culty. Isolated cases might be mistaken at first for acute rheumatism. The
important question of the differentiation between yellow fever and dengue
will be considered later.
Treatment. — This is entirely symptomatic. Quinine is stated to be a
prophylactic, but on insufficient grounds. Hydrotherapy may be employed
to reduce the fever. The salicylates or antipyrin may be tried for the pains,
which usually, however, require opium. During convalescence iodide of potas-
sium is recommended for the arthritic pains, and tonics are indicated.
XIV. CEREBRO-SPINAL FEVER.
Definition. — An infectious disease, occurring sporadically and in epidem-
ics, caused by the diplococcus intraceUidaris, characterized by inflammation
of the cerebro-spinal meninges and a clinical course of great irregularity.
The affection is also known by the names of malignant purpuric fever,
petechial fever, and spotted fever.
158 SPECIFIC INFECTIOUS DISEASES.
History. — Vieusseux first described a small outbreak in Genera in 1805.
In 1806 L. Danielson and E. Mann (Medical and Agricultural Eegister, Bos-
ton) gave an account of " a singular and very mortal disease which lately
made its appearance in Medfield, Mass." The Massachusetts Medical Soci-
ety, in 1809, appointed James Jackson, Thomas Welch, and J. C. Warren to
investigate it. Elisha Xorth's little book (1811) gives a full account of the
early epidemics. Stille's monograph (1867) and the elaborate section in
vol. i of Joseph Jones' works contain details of the later American outbreaks.
In his Geographical Patholog}^ Hirsch divides the outbreaks into four peri-
ods: From 1805 to 1830, in which the disease was most prevalent through-
out the United States; a second period, from 1837 to 1850, when the disease
prevailed extensively in France, and there were a few outbreaks in the United
States; a third period, from 185-i to 1871, when there were outbreaks in
Europe and several extensive epidemics in America. During the Civil War
there were comparatively few cases. It prevailed extensively in the Ottawa
Valley early in the seventies. In the fourth period, from 1875 to the present
time, the disease has broken out in a great many regions. During the past
fifteen years there have been localized outl^reaks in many lands. In the United
States, during 1898-'99, it prevailed in mild form in 27 states. Since 1899
there have been extensive outbreaks in Silesia, and in the cities of the United
States on the Atlantic coast. In Xew York in 190-1-5 there were 6,755 cases
and 3,155 deaths. In the British Isles there have been epidemics in Glasgow
and Belfast, and a few scattered outbreaks. In Glasgow in 1907 there were
nearly 1,000 cases with 595 deaths (Chalmers). In Belfast in the 18 months
ending June, 1908, there were 725 cases with 518 deaths (Eobb).
Etiology. — Cerebro-spinal fever occurs in epidemic and in sporadic
forms. The epidemics are localized, occurring in certain regions, and are
rarely very wide-spread. As a rule, country districts have been more afflicted
than cities. Mining districts and seaports have sufl;ered most severely. The
outbreaks have occurred most frequently in the winter and spring. The con-
centration of individuals, as of troops in large barracks, seems to be a special
factor, and epidemics. on the Continent show how liable recruits and young
soldiers are to the disease. In civil life children and young adults are
most susceptible. Of Koplik's 77 cases 60 per cent were under two years of
age. Over-exertion, long marches in the heat, depressing mental and bodily
surroundings, and the misery and squalor of the large tenement houses in
cities are predisposing causes. The disease seems not to be directly con-
tagious, and is probably not transmitted by clothing or the excretions. It is
very rare to have more than one or two cases in a house, and in a city epidemic
the distribution of the cases is very irregular. Councilman has found five
instances in which the same individual is reported to have had the disease
twice. Meningitis carriers, persons who have the germ in their throats or
noses, but who are themselves unaffected, play an important role in transmit-
ting the disease.
Sporadic cerebro-spinal fever occurs in all the larger cities and in the
country districts of America. The disease lingers in a city indefinitely after
an outbreak, and in Boston, Philadelphia, and Baltimore a moderate number
of cases occur every year. The meningitis in children, known as the simple
or •posterior basic, is the sporadic form. It has two suggestive features of
CEREBROSPINAL FEVER. 159
similarity in the seasonal incidence and in the fact that cases recover. Still
determined the identity of the organism with the meningococcus, and the
view has been confirmed by Koplik and many others. Houston and Rankin
claim that while the cultural peculiarities are the same, the sporadic form
differs in its opsonic and agglutinating powers. The studies of Stuart McDon-
ald and others suggest that it is an attenuated form of the germ.
Bacteriology. — In 1887 Weichselbaum described an organism, the Diplo-
coccus intracellularis meningitidis, which was probably the same as one pre-
viously found by Leichtenstern. In the tissues the organism is almost con-
stantly within the polynuclear leucocytes. In cultures it has well-character-
ized features, and is distinguishable from the pneumococcus. Since Weichsel-
baum's observations this organism has been met with in all carefully studied
epidemics of the disease. The studies of Councilman in Boston and the numer-
ous observers in the Glasgow, Belfast, Kew York, and Silesian epidemics have
confirmed the constancy of this organism in the disease. Three important
facts have been brought out — the presence of the germ in fully half the cases
in the naso-pharynx, the existence of it in healthy contacts, and the prepara-
tion of a curative serum, to be referred to later.
Morbid Anatomy. — In malignant cases there may be no characteristic
changes, the brain and spinal cord showing only extreme congestion, which
was the lesion described by Vieusseux. In a majority of the acutely fatal
cases death occurs within the first week. There is intense injection of the
pia-arachnoid. The exudate is usually fibrino-purulent, most marked at the
base of the brain, where the meninges may be greatly thickened and plastered
over with it. On the cortex there may be much lymph along the larger fissures
and in the sulci ; sometimes the entire cortex is covered with a thick, purulent
exudate. It deserves to be recorded that Danielson and Mann made five autop-
sies and were the first to describe " a fluid resembling pus between the dura
and pia mater." The cord is always involved with the brain. The exudate is
more abundant on the posterior surface, and involves, as a rule, the dorsal
and lumbar regions more than the cervical portion.
In the more chronic cases there is general thickening of the meninges and
scattered yellow patches mark where the exudate has been. The ventricles in
the acute cases are dilated and contain a turbid fluid, or in the posterior
cornua pure pus. In the chronic cases the dilatation may be very great. The
brain substance is usually a little softer than normal and has a pinkish tinge ;
foci of hsemorrhage and of encephalitis may be found. The cranial nerves are
usually involved, particularly the second, fifth, seventh, and eighth. The
spinal nerve roots are also found imbedded in the exudate.
Microscopically, the exudate consists largely of polynuclear leucocytes
closely packed in a fibrinous material. In some instances there are foci of
purulent infiltration and haemorrhage. The neuroglia cells are swollen, with
large, clear, and vesicular nuclei. The ganglion cells show less marked changes.
Diplococci are found in variable numbers in the exudate, being more numer-
ous in the brain than in the cord.
Lesions in Other Parts. — In one of the Boston cases, examination of the
nasal secretion during life showed diplococci, and in this instance there was
found post mortem a purulent infiltration of the mucous membrane. In two
other cases this membrane was normal.
160 SPECIFIC INFECTIOUS DISEASES.
Lungs. — Pneumonia and pleurisy have been described in the disease.
Councilman reports that in the recent epidemic in 13 cases there was con-
gestion Avith cedema, in 7 broncho-pneumonia, in 3 characteristic croupous
pneumonia with pneuinococci ; in 8 pneumonia due to the diplococcus intra-
cellularis was present.
Spleex. — The organ varies a good deal in size. In only three of the
Boston fatal cases was it found much enlarged. The liver is rarely abnormal.
Acute nepliriiis is sometimes present. The intestines show sometimes swelling
of the follicles.
Symptoms. — Cases differ remarkably in their characters. Many different
forms have been described. These are perhaps best grouped into three classes :
1. Malignant Form. — This fulminant or apoplectic t^-pe is found with
variable frequenc}^ in epidemics. It may occur sporadically. The onset is
sudden, usuall}" with violent cliills, headache, somnolence, spasms in the mus-
cles, great depression, moderate elevation of temperature, and feeble pulse,
which may fall to fifty or sixty in the minute. Usually a purpuric rash devel-
ops. In a Philadelphia case, in 1888, a young girl, apparently quite well,
died within twenty hours of this form. There are cases on record in which
death has occurred within a shorter time. Stille tells of a child of five years,
in whom death occurred after an illness of ten hours; and refers to a case
reported by Gordon, in which the entire duration of the illness' was onh' five
hours. Two of Yieusseux's cases died within twent3'-four hours.
2. Ordinary PoRii. — The stage of incubation is not known. The disease
usually sets in suddenly. There may be premonitory s^nnptoms: headache,
pains in the back, and loss of appetite. More commonly, the onset is with
headache, severe chill, and vomiting. The temperature rises to 101° or 103°.
The pulse is full and strong. An early and important s}Tnptom is a painful
stiffness of the muscles of the neck. The headache increases, and there are
photophobia and great sensitiveness to noises. Children become very irritable
and restless. In severe cases the contraction of the muscles of the neck sets
in early, the head is drawn back, and, when the muscles of the back are
also involved, there is orthotonos, which is more common than opisthotonos.
The pains in the back and in the limbs may be very severe. The motor symp-
toms are most characteristic. Tremor of the muscles may be present, with
tonic or clonic spasms in the arms or legs. Eigidity of the muscles of the
back or neck is very common, and the patient lies with the body stiff and the
head drawn so far back that the occiput may be between the shoulder-blades.
Except in early childhood convulsions are not common. Strabismus is a
frequent and important s}Tiiptom. Spasm of the muscles of the face may also
occur. Cases have been described in which the general rigidity and stiffness
was such that the body could be moved like a statue. Paralysis of the trunk
muscles is rare, but paralysis of the muscles of the eye and the face is not
uncommon.
Of sensory symptoms, headache is the most dominant and persists from
the outset. It is chiefly in the back of the head, and the pain extends into
the neck and back. There may be great sensitiveness along the spine, and in
many cases there is general hypersesthesia.
The psychical s}TQptoms are pronounced. Delirium occurs at the onset,
occasionally of a furious and maniacal kind. The patient may display at the
1
CEREBROSPINAL FEVER. 161
start marked erotic symptoms. The delirium gives place in a few days to
stupor, which, as the effusion increases, deepens to coma.
The temperature is irregular and variable. Remissions occur frequently,
and there is no uniform or typical curve during the disease. In some instances
there has been little or no fever. In others the temperature may reach 105°
or 106°, or, before death, 108°. The pulse may be very rapid in children;
in adults it is at first usually full and strong. In some cases it is remark-
ably slow, and may not be more than fifty or sixty in the minute. Sighing
respirations and Cheyne-Stokes breathing are met with in some instances.
Unless there is pneumonia the respirations are not often increased in
frequency.
The cutaneous symptoms of the disease are important. Herpes occurs with
a frequency almost equal to that in pneumonia or intermittent fever. The
petechial rash, which has given the name spotted fever to the disease, is very
variable. Stille states that of 98 cases in the Philadelphia Hospital, no erup-
tion was observed in 37. In the Montreal cases peteehise and purple spots
were common. They appear to have been more frequent in the epidemics on
this continent than in Europe. The petechias may be numerous and cover the
entire skin. An erythema or dusky mottling may be present. In some in-
stances there have been rose-colored hypergemic spots like the typhoid rash.
Urticaria or erythema nodosum, ecthyma, pemphigus, and in rare instances
gangrene of the skin have been noted.
Leucocytosis is an early and constant feature, and ranges from 25,000 to
40,000 per cubic millimetre. It persists even in the most protracted cases.
In one of our cases the diplococcus intracellularis was isolated from the blood
during life.
As already stated, vomiting may be a special feature at the onset; but, as
a rule, it gradually subsides. In some instances, however, it persists and
becomes the most serious and distressing of the symptoms. Diarrhoea is not
common. The bowels are usually confined. The abdomen is not tender. In
the acute form the spleen is usually enlarged.
The urine is sometimes albuminous and the quantity may be increased.
Glycosuria has been noted in some instances, and in the malignant types
hgematuria.
The course of the disease is extremely variable. Hirsch rightly states that
it may range between a few hours and several months. More than half of the
deaths occur within the first five days. In favorable cases, after the symptoms
have persisted for five or six days, improvement is indicated by a lessening of
the spasm, reduction of the fever, and a return of the intelligence. A sudden
fall in the temperature is of bad omen. Convalescence is extremely tedious,
and may be interrupted by complications and sequelae to be noted.
3. Anomalous Forms.
(a) Atoriive Type. — The attack sets in with great severity, but in a day
or two the symptoms subside and convalescence is rapid. Striimpell would
distinguish between this abortive variety, which begins with such intensity,
and the mild ambulant cases described by certain writers. He reports a case
in which the meningeal symptoms set in with the greatest intensity and per-
sisted for four days, the temperature rising to 105.6° F. On the fifth day
the patient entered upon a rapid and satisfactory convalescence. In the mild
12
162 SPECIFIC INFECTIOUS DISEASES.
cases, as distinguished from the abortive, the patients complain of headache,,
nausea, sensations of discomfort in the back and limbs, and stiffness in the
neck. There is little or no fever, and only moderate vomiting. These cases-
could be recognized only during the prevalence of an epidemic.
(h) An Intermittent Type has been observed in many epidemics, and is
recognized by von Ziemssen and Stille. It is characterized by exacerbations,
of fever, which may recur daily or every second day, or follow a curve of an
intermittent or remittent character. The pyrexia resembles that of pyaemia
rather than malaria.
(c) Chronic Form. — Heubner states that this is a relatively frequent
form, though it does not seem to be recognized by many writers on the subject.
An attack may be protracted for from two to five or even six months, and
may cause the most intense marasmus. It is characterized by a series of recur-
rences of the fever, and may present the most complex symptomatology. It
is not improbable that in these protracted cases chronic hydrocephalus or
abscess of the brain is present. This form differs distinctly from the inter-
mittent type. Three cases in our series were of this chronic form; in one
the disease persisted for ninety days.
Complications. — Pleurisy, pericarditis, and parotitis are not uncommon.
Pneumonia is described as frequent in certain outbreaks. Immermann
found, during the Erlangen epidemic, many instances of the combination of
pneumonia with meningitis, but it does not seem possible to determine whether,
in such cases> pneumonia is the primary disease and the meningitis secohdary,
or vice versa. The frequency with which inflammation of the meninges of
the brain complicates pneumonia is well known. Councilman suggests that
the pneumonia of the disease is not the true croupous form, but due to the
diplococcus meningitidis. This was found in eight of the Boston cases, and
in one it was so extensive that it could have been mistaken for the ordinary
croupous pneumonia. Cerebro-spinal fever sometimes prevails extensively with
ordinary pneumonia, as in ISTew York in the winter of 1903-'04. Arthritis
has been the most frequent complication in certain epidemics. Many joints
are affected simultaneously, and there are swelling, pain, and exudation, some-
times serous, sometimes purulent. This was first observed by James Jack-
son, Sr., in the epidemic which he described. Enteritis is rare.
Headache may persist for months or years after an attack. Chronic hydro-
cephalus occurs in certain instances in children. The symptoms of this are
" paroxysms of severe headache, pains in the neck and extremities, vomiting,
loss of consciousness, convulsions, and involuntary discharges of f^ces and
urine" (von Ziemssen). Mental feebleness and aphasia have occasionally
been noted.
Paralysis of individual cranial nerves or of the lower extremities may per-
sist for some time. In some of these cases there may be peripheral neuritis,
as Mills suggested.
Special Senses. — Eye. — Optic neuritis may follow involvement of the nerve
in the exudation at the base. Acute papillitis was found in 6 out of 40 cases
examined by Eandolph. The inflammation may extend directly into the eye
along the pia-arachnoid of the optic nerve, causing purulent choroido-iritiB
or even keratitis. A neuritis of the fifth nerve may be followed by keratiti!5
and purulent conjunctivitis.
I
I
CEREBROSPINAL FEVER. 163
Ear. — Deafness very often follows inflammation of the labyrinth. Otitis
media, with mastoiditis, may occur from direct extension. In 64 cases of
meningitis which recovered, Moos found that 55 per cent were deaf. He sug-
gests that the abortive form of the disease may be responsible for many cases
of early acquired deafness. In children this not infrequently leads to deaf-
mutism. Von Ziemssen states that in the deaf and dumb institutions of Bam-
berg and Nuremberg, in 1874, a majority of the pupils had become deaf from
epidemic cerebro-spinal meningitis.
Nose. — Coryza is not infrequent early in the disease, and Striimpell says
that in many of his cases nasal catarrh preceded the meningitis. He suggests
that the latter may be caused by infection from the nose. Certainly the nasal
secretion appears frequently to contain the diplococci — in 18 cases examined by
Scherrer, and in 10 out of 15 of the Boston cases.
Diagnosis. — Much has been done of late to enable the practitioner to
recognize definitely the existence of meningitis and of the various forms.
(a) The fever, headache, delirium, retraction of the neck, tremor, and
rigidity of the muscles are most important signs. As already mentioned, in
the meningitis of cerebro-spinal fever the spinal symptoms are very much
more marked than in the other forms. One has constantly to bear in mind
that certain cases of typhoid fever and of pneumonia closely simulate cerebro-
spinal meningitis. Long ago Stokes made the wise observation that " there is
no single nervous symptom which may not and does not occur independently
of any appreciable lesion of the brain, nerves, or spinal cord."
(&) Among the special diagnostic features may be mentioned:
Kernig's Sign. — When the thigh is flexed at right angles to the abdomen,
the leg can be extended upon the thigh nearly in a straight line. If menin-
gitis be present, strong contractures of the flexors prevent the full extension
of the leg on the thigh.
Lumbar Puncture. — The procedure is quite harmless, and in a majority
of the cases can be done without general anaesthesia, with the aid of a local
freezing mixture. As a rule, it is best in children to give a whiff or two of
chloroform. The patient is turned on the right side with the back bowed, the
knees drawn up, and the left shoulder forward. As a rule, there is no diffi-
culty in finding the spinal processes, and with the thumb or index finger of
the left hand as a guide, a small aspirator needle or that of the antitoxin
syringe is inserted to one side of the median line and thrust deeply into the
third lumbar interspace in an upward and inward direction. At a variable
distance, according to the age and musculature, the needle enters the spinal
canal — about two and a half centimetres in infants and from four to six centi-
metres in adults.
The fluid runs, as a rule, drop by drop, and when meningitis is present
it is usually turbid, sometimes purulent, occasionally bloody. Meningitis
may be present with a clear fluid. The pressure under which the fluid
flows may reach 250-300 mm., the normal being about 120 mm. Cover-
glass preparations should be made and studied, and the character of the
organisms carefully noted. The cover-slip preparations may give the
diagnosis at once. In acute cases of cerebro-spinal fever the organisms
may be present in large numbers. There is rarely any difficulty in de-
termining between the pneumococcus and the diplococcus intracellularis.
164 SPECIFIC INFECTIOUS DISEASES.
Should the fluid be sterile and tuberculosis 'suspected;, a guinea-pig may be
inoculated. . ,
Prognosis. — Hirsch states that the' mortality has ranged in various epi-
demics from 20 to 75 per cent. In children the death-rate is much higher
than in adults.
Treatment. — The high rate of mortality which has existed in most epi-
demics indicates the fu.iility of the various therapeutical agents which have
been recommended. When we consider the nature of the local disease and
the fact that, so far as we know, tuberculous and other secondary forms of
cerebro-spinal meningitis are invariably fatal, we may wonder rather that
recovery follows in any case.
In strong robust patients the local abstraction of blood by wet cups on
the nape of the neck relieves the pain. General bloodletting is rarely indi-
cated. Cold to the head and spine, which was used in the first epidemics by
New England physicians, is of great service. A bladder of ice to the head,
or an ice-cap, and the spinal ice-l^a^ may be continuously employed. The
latter is very beneficial. Hydrotherapy should be systematically used, in the
form of the tub bath, at 98°, as recommended by Aufrecht. Netter speaks
highly of its good effects, and we have alsovseen it do good. It may be given
every third hour. If any counter-irritation is thought necessary, the skin of
the back of the neck may be lightly touched with the Paquelin thermocautery.
Blisters, which have been used, so much, are of doubtful benefit. The lumbar
puncture seems helpful in cases with coma or convulsions, and in any case it
does no harm. Of internal remedies opium may be given freely, best as mor-
phia hypodermically. Mercury has no special influence on meningeal inflam-
mation. Iodide of potassium is warmly recommended by some writers. Quin-
ine in large doses, ergot, belladonna and Calabar bean have had advocates.
Bromide of potassium may be employed in the milder cases, but it is not so
useful as morphia to control the spasms. Intraspinal injections have been
tried, and in one of our cases Cushing opened and drained the spinal canal.
Diphtheria antitoxin has been used with success in the recent New York
epidemic.
A serum has been prepared and has been used with encouraging success.
Flexner recommends doses of 30 cc. of his serum to be injected directly into
the spinal meninges after the withdrawal of 50 cc. of cerebro-spinal fluid. Of
400 cases thus treated, collected by Flexner and Jobling, 295 recovered.
The diet should be nutritious, consisting of milk and strong broths while
the fever persists. Many cases are very difficult to feed, and Heubner recom-
mends forced alimentation with the stomach-tube. The cases seem to bear
stimulants well, and whisky or brandy may be given freely when there are
signs of a failing heart.
XV. LOBAR PNEUMONIA.
(Croupous or Fibrinous Pneumonia ; Pneumonitis ; Lung Fever.)
Definition. — An infectious disease characterized by inflammation of the
lungs, toxaemia of varying intensity, and a fever that usually terminates by
crisis. Secondary infective processes are common. The Micrococcus lanceo-
lafus of Fraenkel is present in a large proportion of the cases.
LOBAR PNEUMONIA. 165
History. — The disease was known to Hippocrates and the old Greek physi-
cians, by whom it was confounded with pleurisy. Among the ancients, Are-
tseus gave a remarkable description. " Euddy in countenance, but especially
the cheeks ; the white of the eyes very bright and fatty ; the point of the nose
flat ; the veins in the temples and neck distended ; loss of appetite ; .pulse, at
first, large, empty, very frequent, as if forcibly accelerated ; heat indeed, exter-
nally, feeble, and more humid than natural, but, internally, dry and very hot,
by means of which the breath is hot; there is thirst, dryness of the tongue,
desire of cold air, aberration of mind; cough mostly dry, but if anything be
brought up it is a frothy phlegm, or slightly tinged with bile, or with a very
florid tinge of blood. The blood-stained is of all others the worst." At the
end of the seventeenth and the beginning of the eighteenth century Morgagni
and Valsalva made many accurate clinical and anatomical observations on the
disease. Our modern knowledge dates from Laennec (1819), whose masterly
description of the physical signs and morbid anatomy left very little for subse-
quent observers to add or modify.
Incidence. — One of the most wide-spread and fatal of all acute diseases,
pneumonia has become the " Captain of the Men of Death," to use the phrase
applied by John Bunyan to consumption. In England and Wales in 1903
there were 40,725 deaths from this cause; 13,308 were attributed to lobar
pneumonia, 17,435 to broncho-pneumonia, 10 to epidemic pneumonia, 316
to septic pneumonia, while 19,869 were registered as from pneumonia without
further qualification. In 1903 there were 36,536 deaths from all forms of
pneumonia, 31,633 in 1901, and 36,147 in 1900. The total number of deaths
rose above 30,000 in 1890 and 1891 after the influenza, and fell again in 1894
to 18,000 (Tatham). The United States Census Keport for 1900 gives 106.1
deaths from pneumonia per 1,000 deaths, against 90.6 in 1890 and 83.30 in
1880. An apparent increase is noted in the larger cities, particularly N"ew
York and Chicago. In Greater New York in 1904, out of a total of 43,700
deaths, there were 8,360 deaths from pneumonia, 19.5 per cent, against 16.5
per cent in 1903, 17 per cent in 1903, 16 per cent in 1901, and 14.7 per cent
in 1898. In Chicago for the year 1903, out of a total of 38,914 deaths, 4,639,
or 16 per cent, were from pneumonia, an increase of 18 per cent since the
year 1900 (Eeynolds).
Etiology. — Age. — To the sixth year the predisposition to pneumonia is
marked; it diminishes to the fifteenth year, but then for each subsequent
decade it increases. For children Holt's statistics of 500 cases give: First
year, 15 per cent; from the second to the sixth year, 63 per cent; from the
seventh to the eleventh year, 31 per cent; from the twelfth to the fourteenth
year, 3 per cent. Lobar pneumonia has been met with in the new-born. The
relation to age is well shown in the last U. S. Census Eeport for 1900. The
death-rate in persons from fifteen to forty-five years was 100.05 per 100,000
of population; from forty-five to sixty-five years it was 363.13; and in per-
sons sixty-five years of age and over it was 733.77. Pneumonia may well
be called the friend of the aged. Taken off by it in an acute, short, not
often painful illness, the old man escapes those " cold gradations of decay "
so distressing to himself and to his friends.
Sex. — Males are more frequently affected than females.
Eace. — In the United States pneumonia is more fatal in negroes than
166 SPECIFIC INFECTIOUS DISEASES.
among the wMtes. Among the former, at the Johns Hopkins Hospital, the
mortality was rarely under 30 per cent, against an average of about 25 per
cent in the latter.
Social Coxditiox. — The disease is more common in the cities. Individ-
uals who are much exposed to hardship and cold are particularly liable to the
disease. N'ewcomers and immigrants are stated to be less susceptible than
native inhabitants.
Peesonal Condition. — Debilitating causes of all sorts render individuals
more susceptible. Alcoholism is perhaps the most potent predisposing factor.
Eobust, healthy men are, however, often attacked.
Previous Attack. — Xo other acute disease recurs in the same individual
with such frequency. Instances are on record of individuals who have had
ten or more attacks. The percentage of recurrences has been placed as high
as 50. iNTetter gives it as 31, and he has collected the statistics of eleven
observers who place the percentage at 26.8. Among the highest figures for
recurrences are those of Benjamin Push, 28, and Andral, 16.
Teauiia — Coxtusiox-pxeu:moxia. — Pneumonia may follow directly upon
injury, particularly of the chest, without necessarily any lesion of the lung.
Litten gives 4.-1 per cent. Stem 2.8 per cent. There have been several well-
marked cases at the Jolms Hopkins Hospital. Stern describes three clini-
cal varieties : first, the ordinary lobar pneumonia following a contusion of the
chest wall ; secondly, atypical cases, with slight fever and not very characteristic
physical signs ; thirdly, cases with the physical signs and features of broncho-
pneumonia. The last two varieties have a favorable prognosis. According to
Ballard, workers in certain phosphate factories, where they breathe a very
dusty atmosphere, are particularly prone to pneumonia.
Cold has been for years regarded as an important etiological factor. The
frequent occurrence of an initial chill has been one reason for this wide-spread
belief. As to the close association of pneumonia with exposure there can be
no question. "We see the disease occur either promptly after a wetting or a
chilling due to some unusual exposure, or come on after an ordinary catarrh
of one or two day's duration. Cold is now regarded simply as a factor in low-
ering the resistance of the bronchial and pulmonary tissues.
Cli:^iate axd Seasox. — Climate does not appear to have very much iaflu-
ence, as pneumonia prevails equally in hot and cold countries. It is stated to
be more prevalent ia the Southern than in the ISTorthem States, but an exam-
ination of the Census Eeports shows that there is very little difference in the
various state groups.
Much more important is the influence of season. Statistics are almost
unanimous in placing the highest incidence of the disease in the winter and
spring months. In ]\Iontreal, January, the coldest month of the year, but
with steady temperature, has usually a comparatively low death-rate from
pneumonia. The large statistics of Seitz from Munich and of Seibert of New
York give the highest percentage in February and March.
Bacteriology of Acute Lobar Pneumonia. — (a) Miceococcus lanceola-
TUS, PXEUMOCOCCUS OR DiPLOCOCCUS PXEUMOXI^ OF FeAEXKEL AND WeICH-
SELBAmi. — In September, 1880, Sternberg inoculated rabbits with his own
saliva and isolated a micrococcus. The publication was not made until April,
1881. Pasteur discovered the same organism ia the saliva of a child dead
LOBAR PNEUMONIA. 167
of hydrophobia in December, 1880, and the priority of the discovery belongs
to him, as his publication is dated January, 1881. There was, however, no
susoicion that this organism was concerned in the etiology of lobar pneu-
monia, and it was not really until April, 1884, that Fraenkel determined that
the organism found by Sternberg and Pasteur in the saliva, and known as the
coccus of sputum septicaemia, was the most frequent germ in pneumonia.
The organism is a somewhat elliptical, lance-shaped coccus, usually occur-
ring in pairs ; hence the term diplococcus. It is readily demonstrated in cover-
glass preparations with the usual dyes and by the Gram method. About the
organism in the sputum a capsule can always be demonstrated. Its cultural
and biological properties present many variations, for a consideration of which
the student is referred to the text-books on bacteriology. Scarcely any pecul-
iarity is constant. A large number of varieties have been cultivated. Its
kinship to Streptococcus pyogenes is regarded by many as very close, but the
alkaline serum-water medium, containing inulin, recommended by His, serves
to distinguish the pneumococcus from the streptococcus.
Distribution in the Body. — In the bronchial secretions and in the affected
lung the pneumococcus is readily demonstrated in smears, and in the latter
in sections. By using large quantities of blood (3 to 6 cc.) diluted over
twelve times with a liquid culture medium, preferably broth, Kinsey was able
to isolate the pneumococcus from the blood during life in 19 of 25 cases,
(&) Pneumococcus Under Othee Conditions. — (1) In the Mouth. —
The studies of the Kew York Pneumonia Commission have shown that the
pneumococcus is present in the mouths of a large proportion of healthy indi-
viduals, the various observers giving 80 to 90 per cent of positive results.
The virulence is not always uniform, and Langcope and Fox were able to show
that the saliva of the same individual increased in virulence during the winter
months. Some persons always harbor a virulent variety. Buerger at the Mt.
Sinai Hospital studied the communicability of the organism from one person
to another, and it was found repeatedly that normal individuals — i. e., per-
sons in whose mouths the pneumococcus was proved by repeated examinations
to be absent — acquired the organisms by association with cases of pneumonia,
or with healthy persons in whose saliva pneumococci were present.
(2) Outside the Body. — The viability of the pneumococcus is not great.
It has been found occasionally in the dust and sweepings of rooms, but Wood
has shown (New York Commission Eeport) that the germs exposed to sun-
light die in a very short time — an hour and a half being the limit. In moist
sputum kept in a dark room the germs lived ten days, and in a badly ven-
tilated room in which a person with pneumonia coughed, the germs suspended
in the air retained their vitality for several hours.
(3) The Pneumococcus in Other Diseases. — ^The organism is very widely
distributed, and occurs in many conditions other than croupous pneumonia.
An acute septiccemia without local lesion may occur, resembling the typhoid
septicaemia, already described. In a case reported by Townsend, a girl, aged six,
had pain in the abdomen, vomiting, and a temperature of 104.2°. There
was no exudate in the throat. She died thirty hours after the onset of the
symptoms. There was found a general infection with the pneumococcus in
blood, lungs, spleen, and kidneys. As Eosenau has shown, a bacteriasmia may
precede the development of the local lesion in the lungs. In terminal infec-
168 SPECIFIC INFECTIOUS DISEASES.
tions the pneiunococcus plays an important role. Flexner found it four times
in acute peritonitis, eleven times in acute pericarditis, five times in acute endo-
carditis, and three times both in pleurisy and in acute meningitis.
The germ has been associated with wide-spread epidemics of catarrh of
the upper air passages, pneumococcus catarrh, almost like influenza, and some-
times with gastro-intestinal disturbances.
An extraordinary number of local affections are due to the pneumococcus.
It is a common cause of the primary and secondary hronclio-pneumonias.
Infection of the accessory nasal sinuses is most important. Darling found
them involved in 93 per cent of all pneumococcus infections coming to autopsy
at Panama. Meningitis may be associated with pneumonia or endocarditis,
but the so-called primary pneumococcus meningitis is almost always secondary
to sinus infection, 90 per cent in 25 cases (Darling). Pericarditis, endocar-
ditis, empyema, peritonitis, arteritis, conjunctivitis, otitis may be primary
infections with this ubiquitous germ.
(c) Bacillus pneumoxi^ of Feiedlaxdee. — This is a larger organism
than the pneumococcus, and appears in the form of plump, short rods. It also
shows a capsule, but presents marked biological and cultural differences from
Fraenkel's pneumococcus. It occurred in 9 of Weichselbaum's 129 cases. It
may cause broncho-pneumonia and other affections, but probably is not a
cause of genuine lobar pneumonia. The exudate in pneumonias caused by
this bacillus is usually more viscid and pnnrpr in fibrin than tbat in dipla-
coccus pneumonias.
(fZ) Other Organisms. — Various bacteria ma}^ be associated with the
pneumococcus in lobar pneumonia, the most common of these being Strep-
tococcus pyogenes, the pyogenic staphylococci, and Friedlander's pneumo-
bacillus; but while these latter may cause broncho-pneumonias, the)'' have
not been satisfactorily demonstrated to be other than secondary invaders
in lobar pneumonia. Likewise the pneumonias caused by Bacillus typhosus,.
Bacillus diphtherice, and the influenza bacillus are not to be identified with
true lobar pneumonia.
Clinically, the infectious nature of pneumonia was recognized long before
we knew anything of the pneumococcus. Among the features which favored
this view were the following: First, the disease is similar to other infections
in its mode of outbreak. It may occur in endemic form, localized in certain
houses, in barracks, jails, and schools. As many as ten occupants of one house
have been attacked. I have seen three members of a family consecutively
attacked with a most malignant t}^pe of pneumonia. Among the more remark-
able endemic outbreaks is that reported by W. B. Eodman, of Frankfort, Ky.
In a prison with a population of 735 there occurred in one year 118 cases of
pneumonia with 25 deaths. The disease may assume epidemic proportions. In
the Middlesborough epidemic, so carefully studied by Ballard, there were 682
persons attacked, with a mortality of 21 per cent. During some years pneu-
monia is so prevalent that it is practically pandemic. Direct contagion is
suggested by the fact that a patient in the next bed to a pneumonia case may
take th£^3ispasp, or !<3.fir_3 cases may follow in rapid succession m a ward. iF
is very exceptional, however, for nurses or doctors to be attacked.
Secondly, as inother acute infections, the constitutional symptoms may
bear^no_gro£ortion whatever_to_the severity of the local lesion. As is^ well
LOBAR PNEUMONIA. 169
known, a patient may have a very small apex pneumonia which does not seri-
"on8ly~inrpair the breathing capacity, but which may be accompanied with the,
most intensetoxic features,;
■ Thirdly, the" clinical course of the disease is that of an acute infection.
It is the very type of a self -limited disease, running a definite cycle in a
way seen only in infectious disorders.
Conditions Favoring Infection. — Some have already been referred to, but
of many we are still ignorant. The one all-important fact, emphasized by
the work of the New York Commission, is that a majority of us harbor the
germ in mouth or nose or throat. It has been shown that the virulence varies
at different periods, and with this may be associated the well-known seasonal
prevalence of the disease. Some individuals are less resistant, and in no
other acute disease may so many successive attacks occur in the same person.
It is notorious that the negro race in the United States, in Panama, and in
South Africa shows an extreme susceptibility ; on the other hand, the Chinese
in the South African compounds show an extraordinary resistance to the
disease (Porter). Probably for each one of us it is a battle between the
degree of resistance and the virulence of the organism which we harbor. A
catarrh of the upper air passages, exposure, alcoholism, etc., weaken the
defences, and give the ever-present enemy a chance, either for a frontal attack
in the lungs, in an acute pneumonia, or to make a flanking assault, on some
unprotected region, causing a peritonitis, otitis, sinusitis, etc.
Immunity and Serum Therapy. — The pneumococcus does not produce in
artificial cultures any strong, soluble toxin analogous to the diphtheria toxin
or the tetanus toxin, but its poison is contained within the bacterial cells,
from which it may be extracted in various ways, or it may be set free from
the dead or degenerated cocci. The possibility that the pneumococcus may
secrete a soluble toxin in the infected human or animal body may be admitted,
but of this there is no conclusive demonstration. By the use of living or
dead pneumococci or their extracts, animals may be vaccinated against this
organism, so that their blood-serum is capable of protecting susceptible ani-
mals against many times the minimal fatal dose of the virulent pneumococcus.
Strong protective serum has thus been obtained from rabbits, horses, asses,
cows, and other animals subjected to repeated inoculations with dead and liv-
ing cultures of the pneumococcus. This specific serum is neither antitoxic
nor bactericidal. Metchnikoft' believes that it acts by stimulating the leuco-
cytes to ingest and destroy the pneumococci, but A. E. Wright and Douglas
have shown that the protective constituent, which they call an opsonin, enters
into chemical combination with the cocci, rendering them thereby more read-
ily engulfed and digested by the phagocytes. Neufeld and Rimpau have
reached a similar conclusion as to the mode of action of this immune serum.
M. Wassermann fmds that the specific protective substances are formed in
the bone-marrow, and thence distributed to the blood. There is evidence that
similar specific substances are produced in human beings infected with this
organism, and the crisis of pneumonia is explained by the formation and accu-
mulation of these substances in the body.
Many trials have been made of the curative value of antipneumococcic
serum in the treatment of pneumonia, the serum made by Pane having been
most extensively employed. Thus far it has not been shown that this serum
170 SPECIFIC INFECTIOUS DISEASES.
influences in any marked degree the course of the disease in man. Passler
claims to have observed favorable results from the use of a polyvalent serum
prepared according to a method devised by Eomer, and he advocates its
emplo3'ment especially in patients with symptoms of severe infection.
Morbid Anatomy. — Since the time of Laennec, pathologists have recog-
nized three stages in the inflamed lung: engorgement, red hepatization^ and
gray hepatization.
In the stage of engorgement the lung tissue is deep red in color, flrmer
to the touch, and more solid, and on section the surface is bathed with
blood and serum. It still crepitates, though not so distinctly as healthy lung,
and excised portions float. The air-cells can be dilated by insufflation from
the bronchus. The capillary vessels are greatly distended, the alveolar epi-
thelium swollen, and the air-cells occupied by a variable number of blood-
corpuscles and detached alveolar cells. In the stage of red hepatization the
lung tissue is solid, firm, and airless. If the entire lobe is involved it looks
voluminous, and shows indentations of the ribs. On section, the surface is
dry, reddish-brown in color, and has lost the deeply congested appearance
of the first stage. One of the most remarkable features is the friability; in
striking contrast to the healthy lung, which is torn with difficulty. The sur-
face has a granular appearance due to the fibrinous plugs filling the air-cells.
The distinctness of this appearance varies greatly "with the size of the alveoli,
which are about 0.10 mm. in diameter in the infant, 0.15 or 0.16 in the adult,
and from 0.20 to 0.25 in old age. On scraping the surface with a knife a
reddish viscid serum is removed, containing small granular masses. The
smaller bronchi often contain fibrinous plugs. If the limg has been removed
before the heart, it is not uncommon to find solid moulds of clot filling the
blood-vessels. Microscopically, the air-cells are seen to be occupied by coagu-
lated fibrin in the meshes of which are red blood-corpuscles, mononuclear and
pohmuclear leucocytes, and alveolar epithelium. The alveolar walls are infil-
trated and leucocytes are seen in the interlobular tissues. Cover-glass prepa-
rations from the exudate, and thin sections show, as a rule, the diplococci
already referred to, many of which are contained within cells. Staphylococci
and streptococci may also be seen in some cases. In the stage of gray hepatiza-
tion the tissue has changed from a reddish-brown to a grayish-white color.
The surface is moister, the exudate obtained on scraping is more turbid, the
granules in the acini are less distinct, and the lung tissue is still more friable.
The air-cells are densely filled with leucoc}i:es, the fibrin network and the
red blood-corpuscles have largely disappeared. A more advanced condition
of gray hepatization is that known as purulent infiltration, in which the lung
tissue is softer and bathed with a purulent fluid. Small abscess cavities may
form, and by their fusion larger ones, though this is a rare event in ordinary
pneumonia.
Resolution. — The changes in the exudate which lead to its resolution are
due to an autolytic digestion by proteohi:ic enz}Tnes which are present much
more abundantly in gray hepatization than in the preceding stage. The dis-
solved exudate is for the most part excreted by the kidneys. By following the
nitrogen excess in the urine the progress of resolution may be followed and
even an estimate formed of the amount of the exudate thus eliminated. In
a study from my clinic H. W. Cook found in cases of delayed resolution that
LOBAR PNEUMONIA. 171
the nitrogen excess in the urine (which persisted until the lung was clear)
was very large, and he suggests that delayed resolution may really be a matter
of continued exudation.
General Details of the Morbid Anatomy. — In 100 autopsies, made by me
at the General Hospital, Montreal, in 51 cases the right lung was affected, in
32 the left, in 17 both organs. In 27 cases the entire lung, with the excep-
tion, perhaps, of a narrow margin at the apex and anterior border, was con-
solidated. In 34 cases, the lower lobe alone was involved; in 13 cases, the
upper lobe alone. When double, the lower lobes were usually affected together,
but in three instances the lower lobe of one and the upper lobe of the other
were attacked. In 3 cases, also, both upper lobes were affected. Occasion-
ally the disease involves the greater part of both lungs; thus, in one instance
the left organ with the exception of the anterior border was uniformly hepa-
tized, while the right was in the stage of gray hepatization, except a still
smaller portion in the corresponding region. In a third of the cases, red and
gray hepatization existed together. In 22 instances there was gray hepatiza-
tion. As a rule the unaffected portion of the lung is congested or oedematous.
When the greater portion of a lobe is attacked, the uninvolved part may be in
a state of almost gelatinous oedema. The unaffected lung is usually congested,
particularly at the posterior part. This, it must be remembered, may be
largely due to post-mortem subsidence. The uninflamed portions are not
always congested and oedematous. The upper lobe may be dry and bloodless
when the lower lobe is uniformly consolidated. The average weight of a
normal lung is about 600 grammes, while that of an inflamed organ may be
1.500, 2,000, or jeven 2,500 grammes.
The bronchi contain, as a rule, at the time of death a frothy serous fluid,
rarely the tenacious mucus so characteristic of pneumonic sputum. The
mucous membrane is usually reddened, rarely swollen. In the affected areas
the smaller bronchi often contain fibrinous plugs, which may extend into the
larger tubes, forming perfect casts. The bronchial glands are swollen and
may even be soft and pulpy. The pleural surface of the inflamed lung is
invariably involved when the process becomes superficial. Commonly, there
is only a thin sheeting of exudate, producing slight turbidity of the mem-
brane. In only two of the hundred instances the pleura was not involved.
In some cases the fibrinous exudate may form a creamy layer an inch in thick-
ness. A serous exudation of variable amount is not uncommon.
Lesions in Other Organs. — The heart, particularly its right chamber, is dis-
tended with firm, tenacious coagula, which can be withdravm from the vessels
as dendritic moulds. In no other acute disease do we meet with coagula of
such solidity. The spleen is often enlarged, though in only 35 of the 100
cases was the weight above 200 grammes. The kidneys show parenchymatous
swelling, turbidity of the cortex, and, in a very considerable proportion of the
cases — 25 per cent — chronic interstitial changes.
Pericarditis is not infrequent, and occurs more particularly with pneu-
monia of the left side and with double pneumonia. In 5 of the 100 autop-
sies it was present, and in 4 of them the lappet of lung overlying the peri-
cardium with its pleura was involved. Endocarditis is more frequent and
occurred in 16 of the 100 cases. In 5 of these the endocarditis was of the
simple character; in 11 the lesions were ulcerative. Of 209 cases of malig-
172 SPECIFIC INFECTIOUS DISEASES.
nant endocarditis Avhich I collected from the literature, 54 occurred in pneu-
monia. Kanthack found an antecedent pneumonia in 14.2 per cent of cases
of infective endocarditis. In the recent figures collected by E. F. Wells, of
517 fatal cases of acute endocarditis, 22,3 per cent were in pneumonia. It is
more common on the left than on the right side of the heart. Of 61 of a
series of 107 cases of endocarditis in Professor Welch's laboratory in which
cultures were made, pneumococci were found in 21. In 7 of the cases there
was a general pneumoeoccic infection. Myocarditis and fatty degeneration of
the heart may be present in protracted cases.
Meningitis, which is not infrequent, may be associated with malignant
endocarditis. It was present in 8 of the 100 autopsies. Of 20 cases of menin-
gitis in ulcerative endocarditis 15 occurred in pneumonia. The meningitis is
usually of the convex.
Croupous or diphtheritic inflammation may occur in other parts. A croup-
ous colitis, as pointed out by Bristowe, is not very uncommon. It occurred
in 5 of my 100 post mortems. It is usually a thin, flaky exudation, most
marked on the tops of the folds of the mucous membrane. In one case there
was a patch of croupous gastritis, covering an area 2 by 8 cm., situated to the
left of the cardiac orifice.
The liver shows parenchymatous changes, and often extreme engorgement
of the hepatic veins.
Symptoms. — Course of the Disease in Typical Cases. — We know but
little of the incubation period in lobar pneumonia. It is probably very short.
There are sometimes slight catarrhal symptoms for a day or two. As a rule,
the disease sets in jhruptly with a severe chill, which lasts from fifteen to
thirty minutes or longer! In no acute disease is an initial chill so constant
or so severe. The patient may be taken abruptly in the midst of his work, or
may awaken out of a sound sleep in a rigor. The temperature taken during
the chill shows that the fever has already begun. If seen shortly after the
onset, the patient has usually features of an acute fever, and complains of
headache and general pains. Within a few hours there is pain in the side,
often of an agonizing character; a short, dry, painful cough begins, and the
respirations are increased in frequency. Wlien seen on the second or third
day, the picture in typical pneumonia is more distinctive than that presented
by any other acute disease. The patient lies flat in bed, often on the affected
side; the face is flushed, particularly one or both cheeks; the breathing is
hurried, accompanied often with a short expiratory grunt; the alae nasi dilate
with each inspiration ; herpes is usually present on the lips or nose ; the eyes
are bright, the expression is anxious, and there is a frequent short cough
which makes the patient wince and hold his side. The expectoration is
blood-tinged and extremely tenacious. The temperature may be 104° or
105°. The pulse is full and bounding and the pulse-respiration ratio much
disturbed. Examination of the lungs shows the physical signs of consolida-
tion— ^blowing breathing and fine rales. After persisting for from seven to
ten days the crisis occurs, and with a fall in the temperature the patient passes
from the condition of extreme distress and anxiety to one of comparative
comfort.
Special Features. — The fever rises rapidly, and the height may be 104° or
105° within twelve hours. Having reached the fastigium, it is remarkably
LOBAR PNEUMONIA.
173
constant. Often the tAvo-hour temperature chart will not show for two days
more than a degree of variation. In children and in cases without chill the
Jan. 10 H i2 i3 li is 16 17 IS 10
Beep.
Euke
190
Temp,
109
96
Temp.
Reap,
Stools
Urine
)ay of
BLACK, TEMPERATURE J RED, PULSE J BLUE, RESPIRATiON.
Chart X. — Fever, Pulse, and Respiration in Lobar Pneumonia.
rise is more gradual. In old persons and in drunkards the temperature range
is lower than in children and in healthy individuals ; indeed, one occasionally
meets with an afebrile pneumonia.
174 SPECIFIC INFECTIOUS DISEASES.
The Ceisis. — After the fever has persisted for from five to nine or ten
days there is an abrupt drop, known as the crisis, which is one of the most
characteristic features of the disease. The day of the crisis is variable. It
is very uncommon before the third day, and rare after the twelfth. I have
seen it as early as the third day. From the time of Hippocrates it has been
thought to be more frequent on the uneven days, particularly the fifth and
seventh. A precritical rise of a degree or two may occur. In one case the
temperature rose from 105° to nearly 107°, and then in a few hours fell to
normal. ISTot even after the chill in malarial fever do we see such a prompt
and rapid drop in the temperature. The usual time is from five to twelve
hours, but often in an hour there ma}^ occur a fall of sis or eight degrees
(S. West). The temperature may be subnormal after the crisis, as low as
96° or 97°. Usually there is an abundant sweat, and the patient sinks into
a comfortable sleep. The day after the crisis there may be a slight post-critical
rise. A pseudo-crisis is not very uncommon, in which on the fifth or sixth
day the temperature drops from 104° or 105° to 102°, and then rises again.
When the fall takes place gradually witliin twenty-four hours it is called a
protracted crisis. If the fever persists beyond the twelfth day, the fall is
likely to be by lysis. In children this mode of termination is common, and
occurred in one-third of a series of 183 cases reported by Morrill. Occasion-
ally in debilitated individuals the temperature drops rapidly just before death;
more frequently there is an ante-mortem elevation. In cases of delayed reso-
lution the fever may persist for six or eight weeks. The crisis is the most
remarkable single phenomenon of pneumonia. With the fall in the fever the
respirations become reduced almost to normal, the pulse slows, and the patient
passes from perhaps a state of extreme hazard and distress to one of safety
and comfort, and yet, so far as the physical examination indicates, there is
with the crisis no special change in the local condition in the lung.
Pain. — There is early a sharp, agonizing pain, generally referred to the
region of the nipple or lower axilla of the affected side, and much aggravated
on deep inspiration and on coughing. It is associated, as Aretaus remarks,
with involvement of the pleura. It is absent in central pneumonia, and much
less frequent in apex pneumonia. The pain may be severe enough to require
a hypodermic injection of morphia. As has been recognized for many
years, the pain may be altogether abdominal, either central or in the right
iliac fossa, suggesting appendicitis. Crozer Griffith, calling attention to the
frequency of the simulation in children, reports 8 cases, and has collected
34 cases from the literature, many in adults. The operation for appendicitis
has been performed.
Dyspnoea is an almost constant feature. Even early in the disease the res-
pirations may be 30 in the minute, and on the second or third day between
40 and 50. The movements are shallow, evidently restrained, and if the
patient is asked to draw a deep breath he cries out with the pain. Expiration
is frequently interrupted by an audible grunt. At first with the increased
respiration there may be no sensation of distress. Later this may be present
in a marked degree. In children the respirations may be 80 or even 100.
Many factors combine to produce the shortness of breath — the pain in the
side, the toxaemia, the fever, and the loss of function in a considerable area
of the lung tissue. Sometimes there appear to be nervous factors at work.
LOBAR PNEUMONIA. 175
That it does not depend upon the consolidation is shown by the fact that
after the crisis, without any change in the local condition of the lung, the
number of respirations may drop to normal. The ratio between the respira-
tions and the pulse may be 1 to 2 or even 1 to 1.5, a disturbance rarely so^
marked in any other disease.
Cough. — This usually comes on with the pain in the side, and at first is
dry, hard, and without any expectoration. Later it becomes very characteris-
tic— frequent, short, restrained, and associated with great pain in the side.
In old persons, in drunkards, in the terminal pneumonias, and sometimes in
young children, there may be no cough. After the crisis the cough usually
becomes much easier and the expectoration more easily expelled. The cough
is sometimes persistent, continuous, and by far the most aggravated and dis-
tressing symptom of the disease. Paroxysms of coughing of great intensity
after the crisis suggest a pleural exudate.
Sputum. — A brisk haemoptysis may be the initial symptom. At first the
sputum may be mucoid, but usually after twenty-four hours it becomes blood-
tinged, viscid, and very tenacious. At first quite red from the unchanged
blood, it gradually becomes rusty or of an orange 3'^ellow.- The tenacious
viscidity of the sputum is remarkable ; it often has to be wiped from the lips
of the patient. When jaundice is present it may be green or yellow. In low
types of the disease the sputum may be fluid and of a dark brown color^
resembling prune juice. The amount is very variable, ranging from 100 to
300 cc. in the twenty-four hours. In 100 cases in my clinic studied by Emer-
son, in 16 there was little or no sputum; in 32 it was typically rusty; in 33
blood-streaked ; in 3 cases the sputum was very bloody. In children and very
old people there may be no sputum whatever. After the crisis the quantity
is variable, abundant in some cases, absent in others.
Microscopically, the sputum consists of leucocytes, mucus corpuscles, red
blood-corpuscles in all stages of degeneration, and bronchial and alveolar
epithelium. Hsematoidin crystals are occasionally met with. Of micro-organ-
isms the pneumococcus is usually present, and sometimes Friedlander's bacillus
and the influenza bacillus. Very interesting constituents are small cell moulds
of the alveoli and the fibrinous casts of the bronchioles; the latter may be
very plainly visible to the naked eye, and sometimes may form good-sized
dendritic casts. Chemically, the expectoration is particularly rich in calcium
chloride.
Physical Signs. — Inspection. — The position of the patient is not con-
stant. He usually rests more comfortably on the affected side, or he is propped
up with the spine curved toward it. Orthopnoea is rare.
In a small lesion no differences may be noted between the sides; as a
rule, movement is much less on the affected side, which may look larger.
With involvement of a lower lobe, the apex on the same side may show greater
movement. The compensatory increased movement on the sound side is some-
times very noticeable even before the patient's chest is bared. The intercostal
spaces are not usually obliterated. When the cardiac lappet of the left upper
lobe is involved there may be a marked increase in the area of visible cardiac
pulsation. Pulsation of the affected lung may cause a marked movement of
the chest wall (Graves). Other points to be noticed in the inspection are the
frequency of the respiration, the action of the accessory muscles, such as the
176 SPECIFIC INFECTIOUS DISEASES.
sterno-cleido-mastoids and scaleni, and the dilatation of the nostrils with each
inspiration.
Mensuration may show a definite increase in the volume of the side
affected, rarely more, however, than 1 or 1^ cm.
Palpation. — The lack of expansion on the affected side is sometimes more
readily perceived by touch than b}'' sight. The pleural friction may be felt.
On asking the patient to count, the voice fremitus is greatly increased in com-
parison with the corresponding point on the healthy side. It is to be remem-
bered that if the bronchi are filled with thick secretion, or if, in what is
known as massive pneumonia, they are filled with fibrinous exudate, the tac-
tile fremitus may be diminished. It is always well to ask the patient to cough
before testing the fremitus.
Percussion. — In the stage of engorgement the note is higher pitched and
may have a somewhat tympanitic quality, the so-called Skoda's resonance.
This can often be obtained over the lung tissue just above a consolidated area.
L. A. Conner calls attention to a point which all observers must have noticed,
that, when the patient is lying on his side, the percussion at the dependent
base is " deeper and more resonant than that of the upper side," which by con-
trast may seem abnormal, and there may even be a faint tubular element added
to the vesicular breathing on the compressed side. When the lung is hepa-
tized, the percussion note is dull, the qualit}^ varying a good deal from a note
which has in it a certain tympanitic quality to one of absolute flatness. There
is not the wooden flatness of effusion and the sense of resistance is not so great.
During resolution the tympanitic quality of the percussion note usually re-
turns. For weeks or months after convalescence there may be a higher-
pitched note on the affected side. Wintrich's change in the percussion note
when the mouth is open may be very well marked in pneumonia of the upper
lobe. Occasionally there is an almost metallic quality over the consolidated
area, and when this exists with a very pronounced amphoric quality in the
breathing the presence of a cavity may be suggested. In deep-seated pneu-
monias there may be for several days no change in the percussion note.
Auscultation, — Quiet, suppressed breathing in the affected part is often
a marked feature in the early stage, and is always suggestive. Only in a few
cases is the breathing harsh or puerile. Yery early there is heard at the end
of inspiration the fine crepitant ]'ale,a series of minute cracklings heard close
to the ear, and perhaps not audible until a full breath is drawn. This is prob-
ably a fine pleural crepitus, as J. B. Leaming maintained; it is usually be-
lieved to be produced in the air-cells and finer bronchi by the separation of
the sticky exudate. In the stage of red hepatization and when dulness is well
defined, the respiration is tubular, similar to that heard in health over the
larger bronchi. It is heard first with expiration (a point noted by James
Jackson, Jr.), and is soft and of low pitch. Gradually it becomes more in-
tense, and finally presents an intensit}^ unknown in any other pulmonary
affection — of high pitch, perfectly dry. and of equal length with inspiration
and expiration. It is simply the propagation of the laryngeal and tracheal
sounds through the bronchi and the consolidated lung tissue. The permea-
bility of the bronchi is essential to its production. Tubular breathing is absent
in the excessively rare cases of massive pneumonia in which the larger bronchi
are completely filled with exudation. When resolution begins mucous rales
LOBAR PNEUMONIA. 177
of all sizes can be heard. At first they are small and have been called the
redux-crepitus. The voice-sounds and the expiratory grunt are transmitted
through the consolidated lung with great intensity. This bronchophony may
have a carious nasal quality, to which the term aegophony has been given.
There are cases in which the consolidation is deeply seated — so-called central
pneumonia, in which the physical signs are slight or even absent, yet the
cough, the rusty expectoration, and general features make the diagnosis
certain.
Circulatory Symptoms. — During the chill the pulse is small, but in the
succeeding fever it becomes full and bounding. In cases of moderate severity
it ranges from 100 to 116. It is not often dicrotic. In strong, healthy indi-
viduals and in children there may be no sign of failing pulse throughout
the attack. With extensive consolidation the left ventricle may receive a
very much diminished amount of blood and the pulse in consequence may
be small. In the old and feeble it may be small and rapid from the outset.
The pulse may be full, soft, very deceptive, and of no value whatever in
prognosis.
Blood Pressuee. — During the first few days there is no change. The'
extent of involvement seems to have no effect upon the peripheral blood pres-
sure. In the toxic cases the pressure may begin to fall early; a drop of 15-20
mm. Hg. is perfectly safe, but a progressive fall indicates the need of stimula-
tion. A sudden drop is rarely seen except just before death. A slow, gradual
fall of more than 20 mm. Hg. means cardio-vascular asthenia, and calls for an
increase in the stimulation. The crisis has no efl^ect on the blood pressure.
The heart-sounds are usually loud and clear. During the intensity of the fever,
particularly in children, hruits are not uncommon both in the mitral and in
the pulmonic areas. The second sound over the pulmonary artery is accen-
tuated. : Attention to this sign gives a valuable indication as to the condition
of the lesser circulation. With distention of the right chambers and failure
of the right ventricle to empty itself completely the pulmonary second sound
becomes much less distinct. When the right heart is engorged there may be
an increase in the dulness to the right of the sternum. With gradual heart
weakness and signs of dilatation the long pause is greatly shortened, the
sounds approach each other in tone and have a foetal character (embryo-
cardia).
There may be a sudden early collapse of the heart with very feeble, rapid
pulse and increasing cyanosis. I have known this to occur on the third day.
Even when these symptoms are very serious recovery may take place. In
other instances without any special warning death may occur even in robust,
previously healthy men. The heart weakness may be due to paralysis of the
vaso-motor centre and consequent lowering of the general arterial pressure.
The soft, easily compressed pulse, with the gray, ashy facies, cold hands and
feet, the clammy perspiration, and the progressive prostration tell of a toxic
action on the vaso-motor centres. Endocarditis and pericarditis will be con-
sidered under complications. '
BLOODi — Anaemia is rarely seen. Bollinger has called attention to an
oligaemia due to the large amount of exudate. A decrease in the red cells may
occur %% the, time of the crisis. There is in most cases a leucocytosis, which
appears early, persists, and disappears with the crisis. The leucocytes may
13
178
SPECIFIC INFECTIOUS DISEASES.
number from 12,000 to 40.000 or even 100.000 per cubic millimetre. The
fall in the leucoc].1:es is often slower than the drop in the fever, particularly
when resolution is delayed. The annexed chart shows well the coincident
drop in the fever and in the number of the leucocytes. The leucocytosis bears
relation to the extent of the exudate. In malignant pneumonia the leucocy-
Feb., 1893
16 1 17 1 13 1 19 1 20 1 21 1 22
6m612 6m6l26m612 6m6 126m6 12 6m6 12 6m6
105*
10i°
103°
102°
101°
100°
99°
98°
60,000
10,000
30,000
20,000
18,000
16,000
U,000
12,000
10,000
8,000
_C,000__
i,000
2,000
1
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Chart XI.
tosis may be absent, and in any case the continuous absence ma}'' be regarded as
an unfavorable sign. A striking feature in the blood-slide is the richness and
density of the fibrin network. This corresponds to the great increase in the
fibrin elements, the proportion rising from 4 to 10 parts per thousand. The
blood-plates are greatly increased.
LOBAR PNEUMONIA. 179
Digestive Organs. — The tongue is white and furred, and in severe toxic
cases rapidly becomes dry. Vomiting is not uncommon at the onset in chil-
dren. The appetite is lost. Constipation is more common than diarrhoea.
A distressing and sometimes dangerous symptom is meteorism. Fibrinous,
pneumococcic exudates may occur in the conjunctivae, nose, mouth, prepuce,
and anus (Gary). The liver may be depressed by the large right lung, or
enlarged from the engorged right heart, or as a result of the infection. The
spleen is usually enlarged, and the edge can be felt during a deep inspiration.
Skin. — Among cutaneous symptoms one of the most interesting is the
association of herpes with pneumonia. Not excepting malaria, we see labial
herpes more frequently in this than in any other disease, occurring, as it
does, in from 12 to 40 per cent of the cases. It is supposed to be of favorable
prognosis, and figures have been quoted in proof of this assertion. It may
also occur on the nose, genitals, and anus. Its significance and relation to
the disease are unknown. At the height of the disease sweats are not common,
but at the crisis they may be profuse. Eedness of one cheek is a phenomenon
long recognized in connection with pneumonia, and is usually on the same
side as the disease. A diffuse erythema is occasionally seen, and in rare cases
purpura. Jaundice is referred to among the complications.
Urine. — Early in the disease it presents the usual febrile characters of
high color, high specific gravity, and increased acidity. A trace of albumin
is very common. There may be tube-casts, and in a few instances the exist-
ence of albumin, tube-casts, and blood indicates the presence of an acute
nephritis. The urea and uric acid are usually increased at first, but may be
much diminished before the crisis, to increase greatly with its onset. Eobert
Hutchison's researches show that a true retention of chlorides within the
body takes place, the average amount being about 2 grams daily. It is a more
constant feature of pneumonia than of any other febrile disease, and this
being the ease, a diminution of the chlorides in the urine may be of value in
the diagnosis from pleurisy with effusion or empyema. It is to be remem-
bered that in dilatation of the stomach chlorides may be absent. Hsematuria
is a rare complication.
Cerebral Symptoms. — Headache is common. In children convulsions occur
frequently at the outset. Apart from meningitis, which will be considered
separately, one may group the cases with marked cerebral features into —
First, the so-called cerebral pneumonias of children, in which the disease
sets in with a convulsion, and there are high fever, headache, delirium, great
irritability, muscular tremor, and perhaps retraction of the head and neck.
The diagnosis of meningitis is usually made, and the local affection may be
overlooked.
Secondly, the cases with maniacal symptoms. These may occur at the
very outset, and I once performed an autopsy on a case in which there was
no suspicion whatever that the disease was other than acute mania. The
house physician should give instructions to the nurses to watch such cases
very carefully. On March 22, 1894, a patient who had been doing very well,
with the exception of slight delirium, while the orderly was out of the room
for a few moments, got up, raised the window, and jumped out, sustaining
a fracture of the leg and of the upper lumbar vertebrae, of which he died.
Thirdly, alcoholic cases with the features of delirium tremens. It should
180 SPECIFIC INFECTIOUS DISEASES.
be an invariable rule, even if fever be not present^ to examine the lungs in a
case of mania a potu.
Fourthly, cases with toxic features, resembling rather those of uraemia.
Without a chill and without cough or pain in the side, a patient may have
fever, a little shortness of breath, and then gradually grow dull mentally, and
within three days be in a condition of profound toxgemia with low, muttering
delirium.
It is stated that apex pneumonia is more often accompanied with severe
delirium. Occasionally the cerebral sjonptoms occur immediately after the
crisis. 3Iental disturbance may persist during and after convalescence, and
in a few instances delusional insanity follows, the outlook in which is
favorable.
Complications. — Compared with typhoid fever, pneumonia has but few
complications and still fewer sequelse. The most important are the fol-
lowing :
Pleurisy is an inevitable event when the inflammation reaches the surface
of the lung, and thus can scarcely be termed a complication. But there are
cases in which the pleuritic features take the first place — cases to which the
term pleuro-pneumonia is applicable. The exudation may be sero-fibrinous
with copious effusion, differing from that of an ordinary acute pleurisy in
the greater richness of the fibrin, which may form thick, tenacious, curdy
layers. Pneumonia on one side with extensive pleurisy on the other is some-
times a puzzling complication to diagnose, and an aspirator needle may be
required to settle the question. Empyema is one of the most common com-
plications, and has of late increased in frequency. During the eight 3'ears,
1883-'90, there were at Guy's Hospital 7 cases of emp^-ema among 445 cases
of pneumonia, while in the eight years, 1891-'98, there were 38 cases among
896 cases of pneumonia (Hale White). Influenza may be responsible for the
increase. The pneumococcus is usually present; in a few the streptococcus,
in which case the prognosis is not so good. Eecurrence of the fever after the
crisis or persistence of it after the tenth day, with sweats, leucocytosis, and
perhaps an aggravation of the cough, are suspicious symptoms. The dulness
persists at the base, or may extend. The breathing is feeble and there are no
rales. Such a condition may be closely simulated, of course, by the thickened
pleura. Exploratory aspiration may settle the question at once. There are
obscure cases in which the pus has been found only after operation, as the
collection may be very small.
Pericarditis was present in 31 of 665 patients in my wards at the Johns
Hopkins Hospital (Chatard). It is often a terminal afiair and overlooked.
The mortality is very high; 29 of the 31 cases died. Pleurisy is an almost
constant accompaniment, being present in 28 of the 29 autopsies in our series.
In only 3 cases was the effusion purulent and in large amount.
Endocarditis. — ^^The valves on the left side are more commonly attacked,
and particularly if the seat of arterio-sclerosis. It is particularly liable to
attack persons with old valvular disease. There may be no symptoms indica-
tive of this complication even in very severe cases. It may, however,
be suspected in cases (1) in which the fever is protracted and irregular;
(2) when signs of septic mischief arise, such as chills and sweats; (3) when
embolic phenomena appear. The frequent complication of meningitis with
LOBAR PNEUMONIA. 181
the endocarditis of pneumonia, which has already been mentioned, gives
prominence to the cerebral symptoms in these cases. The physical signs may
be very deceptive. There are instances in which no cardiac murmurs have
been heard. In others the occurrence under observation of a loud, rough mur-
mur, particularly if diastolic, is extremely suggestive.
Thrombosis. — Ante-mortem clotting in the heart, upon which the old
writers laid great stress, is very rare. Thrombosis in the peripheral veins is
also uncommon. Two cases occurred at my clinic, which have been reported
by Steiner, who was able to collect only 41 cases from the literature. In 37
out of 32 cases which were fully reported, the thrombosis occurred during con-
valescence. It is almost always in the femoral veins. A rare complication is
embolism of one of the larger arteries. I saw in Montreal an instance of
embolism of the femoral artery at the height of pneumonia, which necessitated
amputation at the thigh. The patient recovered. Aphasia has been met with
in a few instances, setting in abruptly with or without hemiplegia.
Meningitis is perhaps the most serious complication of pneumonia. It
varies very much at different times and in different regions. My Montreal
experience is rather exceptional, as 8 per cent of the fatal cases had this com-
plication. It usually comes on at the height of the fever, and in the majority
of the cases is not recognized unless, as before mentioned, the base is involved,
which is not common. Occurring later in the disease, it is more easily diag-
nosed. In some cases it is associated with infective endocarditis. The pneu-
mococcus has been found in the exudate.
Peripheral neuritis is a rare complication, of which several cases have been
described.
Gastric complications are rare. A croupous gastritis has already been
mentioned. The croupous colitis may induce severe diarrhoea.
Abdominal Pain. — It is by no means uncommon to have early pain, either
in the region of the umbilicus or in the right iliac fossa, and a suspicion of
appendicitis is aroused; indeed, a catarrhal form of this disease may occur
eoincidently with the pneumonia. In other instances so localized may the pain
be in the region of the pancreas, associated with meteorism and high fever,
that the diagnosis of acute hsemorrhagic pancreatitis is made. Such a case
occurred in February, 1905, in the wards of my colleague Dr. Halsted. The
patient was admitted in a desperate condition, all the symptoms were abdom-
inal, and the apex pneumonia was not discovered. Peritonitis is a rare com-
plication, of which we have had only two or three instances. It is sometimes
in the upper peritonaeum, and a direct extension through the diaphragm. It
is usually in the severer cases and not easy to recognize. In one case, indeed,
in which there was a friction along the costal border, which we thought indi-
cated a peritonitis, it was communicated from the diaphragmatic pleura.
Meteorism is not infrequent, and is sometimes serious. In some cases it may
be due to a defect in the mechanical action of the diaphragm, in others to an
acute septic catarrh of the bowels, or to a toxic paresis of the walls, occasion-
ally to peritonitis. Jaundice occurs with curious irregularity in different
outbreaks of the disease. In Baltimore it was more common among the negro
patients. It sets in early, is rarely very intense, and has not the characters
of obstructive Jaundice. There are cases in which it assumes a very serious
form. The mode of production is not well ascertained. It does not appear
182 SPECIFIC INFECTIOUS DISEASES.
to bear any definite relation to the degree of hepatic engorgement, and it is
not always due to catarrh of the ducts. Possibly it may be, in great part,
hasmatogenons.
Parotitis occasionally occurs, commonly in association with endocarditis.
In children, middle-ear disease is not an infrequent complication.
B right's disease does not often follow pneumonia.
The relations of arthritis and pneiunonia are xers' interesting. It may
precede the onset, and the pneumonia, possibly with endocarditis and pleurisy,
may occur as complications. In other instances at the height of an ordinary
pneumonia one or two joints may become red and sore. On the other hand,
after the crisis has occurred pains and swelling may come on in the joints.
Relapse. — There are cases in which from the ninth to the eleventh day the
fever subsides, and after the temperature has been normal for a day or two a
rise occurs and fever may persist for another ten days or even two weeks.
Though this might be termed a relapse, it is more correct to regard it as an
instance of an anomalous course of delayed resolution. Wagner, who has
studied the subject carefully, says that in his large experience of 1,100 cases
he met with only 3 doubtful cases. "WTien it does occur, the attack is usually
abortive and mild. In the case of Z. E. (Medical Xo. J. H. H., 4223), with
pneumonia of the right lower lobe, crisis occurred on the seventh day, and
after a normal temperature for thirteen days he was discharged. That night
he had a shaking chill, followed by fever, and he had recurring chills with
reappearance of the pneumonia. In a second case (Medical No. J. H. H.,
4538) crisis occurred on the third day, and there was recurrence of pneumonia
on the thirteenth day.
Recurrence is more common in pneumonia than in any other acute disease.
Eush gives an instance in which there were 28 attacks. Other authorities nar-
rate cases of 8, 10, and even more attacks.
Convalescence in pneumonia is usually rapid, and sequelge are rare. After
the crisis, sudden death has occurred when the patient has got up too soon.
With the onset of fever and persistence of the leucocytosis the afEected side
should, be very carefully examined for pleurisy. With a persistence of the
dulness the physical signs may be obscure, but the use of a small exploratory
needle will help to clear the diagnosis.
Clinical Varieties. — Local variations are responsible for some of the most
marked deviations from the usual type.
Apex pneumonia is said to be more often associated with ad}Tiamic fea-
tures and with marked cerebral symptoms. The expectoration and cough may
be slight.
Migratory or creeping pneumonia., a form which successively involves one
lobe after the other.
Douhle pneumonia has no peculiarities other than the greater danger con-
nected with it.
Massive pneumonia is a rare form, in which not alone the air-cells but
the bronchi of an entire lobe or even of a lung are filled with the fibrinous exu-
date. The auscultatory signs are absent; there is neither fremitus nor tubu-
lar breathing, and on percussion the lung is absolutely flat. It closely resem-
bles pleurisy with effusion. The moulds of the bronchi may be expectorated
in violent fits of coughing.
LOBAR PNEUMONIA, 183
Central Pneumonia. — The inflammation may be deep-seated at the root
of the lung or centrally placed in a lobe, and for several days the diagnosis
may be in doubt. It may not be until the third or fourth day that a pleural
friction is detected, or that dulness or blowing breathing and rales are recog-
nized. I saw in 1898 with Drs. H. Adler and Chew a young, thin-chested girl
in whom at the end of the fourth day all the usual symptoms of pneumonia
were present without any physical signs other than a few clicking rales at the
left apex behind. The thinness of the patient greatly facilitated the examina-
tion. The general features of pneumonia continued, and the crisis occurred
on the seventh day.
Pneumonia in Infants. — It is sometimes seen in the new-born. In in-
fants it very often sets in with a convulsion. The apex of the lung seems
more frequently involved than in adults, and the cerebral sjonptoms are more
marked. The torpor and coma, particularly if they follow convulsions, and
the preliminary stage of excitement, may lead to the diagnosis of meningitis.
Pneumonic sputum is rarely seen in children.
Pneumonia in the Aged. — The disease may be latent and set in with-
out a chill; the cough and expectoration are slight, the physical signs ill-
defined and changeable, and the constitutional symptoms out of all propor-
tion to the extent of the local lesion.
Pneumonia in x4.lcoholic Subjects. — The onset is insidious, the symp-
toms masked, the fever slight, and the clinical picture usually that of delirium
tremens. The thermometer alone may indicate the presence of an acute dis-
ease. Often the local condition is overlooked, as the patient makes no com-
plaint of pain, and there may be very little shortness of breath, no cough, and
no sputum.
Terminal Pneumonia. — The wards and the post-mortem room show
a very striking contrast in their pneumonia statistics, owing to the occur-
rence of what may be called terminal pneumonia. During the winter months
patients with chronic pulmonary tuberculosis, arterio-sclerosis, heart disease,
Bright's disease, and diabetes are not infrequently carried off by a pneu-
monia which may give few or no signs of its presence. There may be a slight
elevation of temperature, with increase in the respirations, but the patient
is near the end and perhaps not in a condition in which a thorough physical
examination can be made. The autopsy may show pneumonia of the greater
part of one lower lobe or of the apex, which had entirely escaped notice.
In diabetic patients the disease often runs a rapid and severe course, and may
end in abscess or gangrene.
Some of the most remarkable variations in the clinical course of pneu-
monia depend probably upon the severity, possibly upon the nature of the
infection. Further investigation may enable us to say how far the associated
organisms, so often present, may be responsible for the differences in the
clinical course.
Secondary Pneumonias. — These are met with chiefly in the specific
fevers, particularly diphtheria, typhoid fever, typhus, infiuenza, and the
plague. Anatomically, they rarely present the typical form of red or gray
hepatization. The surface is smoother, not so dry, and it is often a pseudo-
lobar condition, a consolidation caused by closely set areas of lobular involve-
ment. Histologically, they are characterized in many instances by a more
184 SPECIFIC INFECTIOUS DISEASES.
cellular, less fibrinous exudate, which may also infiltrate the alveolar walls,
Bacteriologically, a large number of different organisms have been found,
the specific microbe of the primary disease, usually in association with the
streptococcus pyogenes or the staphylococcus; in some instances the colon
bacillus has been present.
The symptoms of the secondary pneumonias often lack the striking defi-
niteness of the primary croupous pneumonia. The pulmonary features may
be latent or masked altogether. There may be no cough and only a slight in-
crease in the number of respirations. The lower lobe of one lung is most com-
monly involved, and the physical signs are obscure and rarely amount to
more than impaired resonance, feeble breathing, and a few crackling rales.
Epidemic pneumonia has already been referred to. It is, as a rule, more
fatal, and often displays minor complications which differ in different out-
breaks. In some the cerebral manifestations are very marked; in others, the
cardiac; in others again, the gastro-intestinal.
Larval Pneumonia. — Mild, abortive types are seen, particularly in insti-
tutions when pneumonia is prevailing extensively. A patient may have the
initial symptoms of the disease, a slight chill, moderate fever, a few indefi-
nite local signs, and herpes. The whole process may only last for two or three
days; some authors recognize even a one-day pneumonia.
Asthenic, Toxic, or Typhoid Pneumonia. — The toxaemic features
dominate the scene throughout. The local lesions may be slight in extent
and the subjective phenomena of the disease absent. The nervous symptoms
usually predominate. There are delirium, prostration, and early weakness.
Very frequently there is jaundice. Gastro-intestinal symptoms may be pres-
ent, particularly diarrhoea and meteorism. In such a case, seen about the end
of the first week, it may be difficult to say whether the condition is one of
asthenic pneumonia or one of typhoid fever which has set in with early local-
ization in the lung. Here the Widal reaction and cultures from the blood are
important aids. In these cases there is really a pneumococcus septicaemia,
and the organisms may sometimes be isolated from the blood. Possibly, too,
there is a mixed infection, and the streptococcus pyogenes may be in large
part responsible for the toxic features of the disease.
Association op Pneumonia v^^ith Other Diseases. — (a) With Malaria.
— A malarial pneumonia is described by many observers and thought to be
particularly prevalent in some parts of the United States. One hears of it,
indeed, even where true malaria is rarely seen. With our large experience
in malaria, amounting now to between two and three thousand cases, and
a considerable number of pneumonia patients every year, we have only had
a few cases in which the latter disease has set in during malarial fever, or vice
versa. In either case the malaria yields promptly to the action of quinine.
A special form of pneumonia due to the malarial parasite is unknown. Yet
there are cases reported by Craig and others in which in an acute malarial
infection the features suggest pneumonia at the onset, but the parasites are
found in the blood, and under the use of quinine the fever drops rapidly and
the pneumonia symptoms clear up. Such a case as the following we see occa-
sionally: A patient was admitted, March 16, 1894, with tertian malarial fever.
The lungs were clear. A pneumonia began thirty-six hours after admission.
Quinine was given that evening, and the malarial organisms rapidly disap-
LOBAR PNEUMONIA. 185
peared from the blood. There was successive involvement of the right lower,
the middle, and the left lower lobe. The temperature fell by crisis on the
24th, and there were no features in the disease whatever suggestive of malaria.
In other instances we have found a chill in the course of an ordinary pneu-
monia to be associated with a malarial infection, and quinine has rapidly
and promptly caused the disappearance of the parasites from the blood.
(&) Pneumonia and Acute Arthritis. — We have already spoken under
complications of this association, which is more frequently seen in children.
(c) Pneumonia and Tuberculosis. — Many subjects of chronic pulmonary
tuberculosis die of an acute croupous pneumonia. A point to be specially
borne in mind is the fact that acute tuberculous pneumonia may set in with
all the features and physical signs of fibrinous pneumonia (see page 175).
For the consideration of the association of pneumonia with typhoid fever
and influenza, the reader is referred to the sections on those diseases.
PosT-oPEKATiON PNEUMONIA. — Before the days of anesthesia, lobar
pneumonia was a well-recognized cause of death after surgical injuries and
operations. Norman Cheevers, in an early number of the Guy's Hospital
Reports, calls attention to it as one of the most frequent causes of death after
surgical procedures, and Erichsen states that of 41 deaths after surgical in-
juries 23 cases showed signs of pneumonia. The lobular form is the most
frequent. I have already referred to the contusion-pneumonia described by
Litten,
Ether Pneumonia. — The question of a direct relation between ether
narcosis and pneumonia has been much discussed of late years, having been
raised by Mr, Lucas, of Guy's Hospital. The statistics are by no means
unanimous. The London anaesthetists, particularly Hewitt and Silk, seem to
have had a fortunate experience. Silk having found among 5,000 cases 13 of
pneumonia; 8 of these were tongue or jaw cases. The German experience
is very different. Von Beck states that, owing to the injurious after-effects
upon the respiratory tract, the use of ether has been largely restricted in
Czerny's clinic. Gurlt reports 52,177 cases, with 30 cases of pneumonia and
15 deaths. We usually had three or four cases each year at the Johns Hopkins
Hospital. Czerny suggests that the relation of these ether pneumonias to
abdominal operations is associated with the pain on coughing, which leads to
an accumulation of secretion, and through this to retention or aspiration pneu-
monia. Among the various views brought forward to account for it are the
rapid evaporation of the ether, causing chilling of the pulmonarj'^ tissues, chill-
ing of the patient at the time of operation, infection from the inhaler, and
direct action of the ether.
The probability is that the prolonged etherization lowers the vitality of
the tissues of the finer bronchi and permits the pathogenic organisms (which
are almost always present) to do their work. The pneumonia is more fre-
quently lobular than lobar. Neuwerck, and subsequently Whitney, have sug-
gested thorough disinfection of the mouth and throat before operation.
Delayed Resolution in Pneumonia. — The lung is restored to its nor-
mal state by the liquefaction and absorption of the exudate. There are
eases in which resolution takes place rapidly without any increase in (or,
indeed, without any) expectoration; on the other hand, during resolution it is
not uncommon to find in the sputa the little plugs of fibrin and leucocytes
186 SPECIFIC INFECTIOUS DISEASES.
which have been loosened from the air-cells and expelled by coughing, A
yariable time is taken in the restoration of the lung. Sometimes within a
week or ten days the dulness is greatly diminished, the breath-sounds become
clear, and, so far as physical signs are any guide, the lung seems perfectly
restored. It is to be remembered that in any case of pneumonia with extensive
pleurisy a certain amount of dulness will persist for months, owing to thick-
ening of the pleura.
Delayed resolution is a condition which causes much anxiety to the physi-
cian. While it is perhaps more frequent in debilitated persons, jet it is met
with in robust, previously healthy individuals, and in cases which have had
a very typical onset and course. The condition is stated to be most frequent
in apex pneumonia. Venesection has been assigned as a cause. The solid
exudate may persist for weeks and yet the integrity of the lung may ulti-
mately be restored. Grissole describes the lung from a patient who died on
the sixtieth day, in which the affected part showed a condition not unlike that
of the acute stage.
Clinically, there are several groups of cases : First, those in which the
crisis occurs naturally, the temperature falls and remains normal, but the
local features persist — ^well-marked flatness with tubular breathing and rales.
Eesolution may occur very slowly and gradually, taking from two to three
weeks. In a second group of cases the temperature falls by lysis, and with the
persistence of the local signs there is slight fever, sometimes sweats and rapid
pulse. The condition may persist for three or four weeks, or, as in one of my
c^ses, for eleven weeks, and ultimately perfect resolution occur. During all
this time there may be little or no sputum. The practitioner is naturally
much exercised, and he dreads lest tuberculosis should supervene. In a third
group the crisis occurs or the fever falls by lysis, but the consolidation persists
and there may be intense bronchial breathing, with few or no rales, or the fever
may recur and the patient may die exhausted. In 1 of my 100 autopsies a
patient, aged fifty-eight, had died on the thirty-second day from the initial
chill. The right lung was solid, grayish in color, firm, and presented in
places a translucent, semi-homogeneous aspect. In these areas the alveolar
walls were thickened, and the plugs filling the air-cells were undergoing trans-
formation into new connective tissue. This fibroid induration may proceed
gradually and be associated with shrinkage of the affected side, and the gradual
production of a cirrhosis or chronic interstitial pneumonia.
Ordinary fibrinous pneumonia never terminates in tuberculosis. The in-
stances of caseous pneumonia and softening which have followed an acute
pneumonic process have been from the outset tuberculous.
Teemixation in Abscess.- — This occurred in 4 of my 100 autopsies.
Usually the lung breaks down in limited areas and the abscesses are not
large, but they may fuse and involve a considerable proportion of a lobe.
The condition is recognized by the sputum, which is usually abundant and
contains pus and elastic tissue, sometimes cholesterin crystals and hasma-
toidin crystals. The cough is often paroxysmal and of great severity; usu-
ally the fever is remittent, or in protracted cases intermittent in character,
and there may be pronounced hectic symptoms. Wlien a case is seen for the
first time it may be difficult to determine whether it is one of abscess of the
lung or a local empyroma which has perforated the lung.
LOBAR PNEUMONIA. 187
GrANGKENE. — This is most commonly seen in old debilitated persons.
It was present in 3 of my 100 autopsies. It very often occurs with abscess.
The gangrene is associated with the growth of the saproph3^tic bacteria on
a soil made favorable by the presence of the pneumococcus or the strepto-
coccus. Clinically, the gangrene is rendered very evident by the horribly
fetid odor of the expectoration and its characteristic features. In some in-
stances the gangrene may be found post mortem when clinically there has not
been any evidence of its existence.
Prognosis, — Pneumonia is the most fatal of all acute diseases, killing more
than diphtheria, and outranking even consumption as a cause of death.
Hospital statistics show that the mortality ranges from 30 to 40 per cent.
Of 1,012 cases at the Montreal General Hospital, the mortality was 30,4 per
cent. It appears to be somewhat more fatal in southern climates. Of 3,969
cases treated at the Charity Hospital, New Orleans, the death-rate was 38,01
per cent. The mortality at the Johns Hopkins Hospital has been about 35
per cent in the whites and 30 per cent in the colored. In 704 cases at the
Pennsylvania Hospital the mortality was 29 per cent. At the Boston City
Hospital, in 1,443 cases the mortality was 29,1 per cent. It has been urged
that the mortality in this disease has been steadily increasing, and attempts
have been made to connect this increase with the expectant plan of treatment
at present in vogue. But the careful and thorough analysis by C. N". Townsend
and A. Coolidge, Jr,, of 1,000 cases at the Massachusetts General Hospital in-
dicates clearly that, when all circumstances are taken into consideration, this
conclusion is not justified.
According to the analysis of 708 cases at St, Thomas's Hospital by Had-
den, H, W. G. McKenzie, and W. W. Ord, the mortality progressively in-
creases from the twentieth year, rising from 3.7 per cent under that age to 23
per cent in the third decade, 30.8 per cent in the fourth, 47 per cent in the
fifth, 51 per cent in the sixth, 65 per cent in the seventh decade. Of 465,400
cases collected by E. F. Wells from various sources, 94,836 died, a mortality
of 20.4 per cent.
The mortality in private practice varies greatly. E. P. Howard treated
170 cases with only 6 per cent of deaths. Fussell has recently reported 134
cases with a mortality of 17.9 per cent. The mortality in children is some-
times very low. Morrill has recently reported 6 deaths in 123 cases of frank
pneumonia. On the other hand, Goodhart had 25 deaths in 120 cases.
The following are among the circumstances which influence the prog-
nosis :
Age. — As Sturges remarks, the old are likely to die, the young to recover.
Under one year it is more fatal than between two and five. Fussell lost 5 out
of 8 cases in sucklings. At about sixty the death-rate is very high, amounting
to 60 or 80 per cent. From the reports of its fatality in some places, one
may say that to die of pneumonia is almost the natural end of old people.
As already stated, the disease is more fatal in the negro than in the
white race.
Previous habits of life and the condition of bodily health at the time of
the attack form the most important factors in the prognosis of pneumonia.
In analyzing a series of fatal cases one is very much impressed with the num-
ber of cases in which the organs shown signs of degeneration. In 25 of my
188 SPECIFIC INFECTIOUS DISEASES.
100 antopsies at the Montreal General Hospital the kidneys showed extensive
interstitial changes. Individuals debilitated from sickness or poor food, hard
drinkers, and that large class of hospital patients, composed of robust-looking
laborers between the ages of forty-five and sixty, whose organs show signs of
wear and tear, and who have by excesses in alcohol weakened the reserve
power, fall an easy prey to the disease. Very few fatal cases occur in robust,
healthy adults. Some of the statistics given by army surgeons show better
than any others the low mortality from pneumonia in healthy picked men.
The death-rate in the German arm}^ in over 40,000 cases was only 3.6 per cent.
Certain complications and terminations are particularly serious. The
meningitis of pneumonia is probably always fatal. Endocarditis is extremely
grave, much more so than pericarditis. Apart from these serious complica-
tions, the fatal event in pneumonia is due either to a gradual toxsemia or to
mechanical interference with the respiration and circulation.
Much stress has been laid of late upon the factor of leucocytosis as an
element in the prognosis. A very slight or complete absence of a leucocytosis
is rightly regarded as very unfavorable.
Toxcemia is the important prognostic feature in the disease, to which in
a majority of the cases the degree of pyrexia and the extent of consolidation
are entirely subsidiary. It is not at all proportionate to the degree of lung
involved. A severe and fatal toxaemia may occur with the consolidation of
only a small part of one lobe. On the other hand, a patient with complete
solidification of one lung may have no signs of a general infection. The
question of individual resistance seems to be the most important one, and
one sees even most robust-looking individuals fatally stricken within a few
days.
Death is rarely due to direct interference with the function of respira-
tion, even in double pneumonia. Sometimes it seems to be caused by the
extensive involvement with oedema of the other parts of the lungs, an
engorgement with progressive weakness of the right heart. But death is most
frequently due to the action of the poisons on the vaso-motor centres, with
progressive lowering of the blood pressure. This is a much more serious
factor than direct weakness of the heart muscle itself.
Diagnosis. — ISTo disease is more readily recognized in a large majority of
the cases. The external characters, the sputa, and the physical signs combine
to make one of the clearest of clinical pictures. After a study in the post-
mortem room of my own and others' mistakes, I think that the ordinary lobar
pneumonia of adults is rarely overlooked. Errors are particularly liable to
occur in the intercurrent pneumonias, in those complicating chronic affec-
tions, and in the disease as met with in children, the aged, and drunkards.
Tuberculo-pneumonic phthisis is frequently confounded with pneumonia.
Pleurisy with effusion is, I believe, not often mistaken except in children.
The diagnostic points will be referred to under pleurisy.
In diabetes. Bright' s disease, chronic heart-disease, pulmonary phthisis,
and cancer, an acute pneumonia often ends the scene, and is frequently over-
looked. In these cases the temperature is perhaps the best index, and should,
more particularly if cough occurs, lead to a careful examination of the lungs.
The absence of expectoration and of pulmonary symptoms may nlake the diag-
nosis very difiicult.
LOBAR PNEUMONIA. 189
In children there are two special sources of error; the disease may be
entirely masked by the cerebral symptoms and the case mistaken for one of
meningitis. It is remarkable in these cases how few indications there are of
pulmonary trouble. The other condition is pleurisy with effusion, which in
children often has deceptive physical signs. The breathing may be intensely
tubular and tactile fremitus may be present. The exploratory needle is some-
times required to decide the question. In the old and debilitated a knowledge
that the onset of pneumonia is insidious, and that the symptoms are ill-
defined and latent, should put the practitioner on his guard and make him
very careful in the examination of the lungs in doubtful cases. In chronic
alcoholism the cerebral symptoms may completely mask the local process. As
mentioned, the disease may assume the form of violent mania, but more com-
monly the symptoms are those of delirium tremens. In any case, rapid pulse,
rapid respiration, and fever are symptoms which should invariably excite
suspicion of inflammation of the lungs. Under cerebro-spinal meningitis will
be found the points of differential diagnosis between pneumonia and that
disease.
Pneumonia is rarely confounded with ordinary consumption, but to differ-
entiate acute tuberculo-pneumonic phthisis is often difficult. The case may
set in with a chill. It may be impossible to determine which condition is
present until softening occurs and elastic tissue and tubercle bacilli appear
in the sputum. A similar mistake is sometimes made in children. With
typhoid fever, pneumonia is not infrequently confounded. There are in-
stances of pneumonia with the local signs well marked in which the patient
rapidly sinks into what is known as the typhoid state, with dry tongue, rapid
pulse, and diarrhoea. Unless the case is seen from the outset it may be very
difficult to determine the true nature of the malady. On the other hand,
there are cases of typhoid fever which set in with symptoms of lobar pneu-
monia— the so-called pneumo-typhus. It may be impossible to make a differ-
ential diagnosis in such a case unless the characteristic eruption occurs or the
Widal reaction be given.
Prophylaxis. — We do not know the percentage of individuals who harbor
the pneumococcus normally in the secretions of the mouth and throat. In a
great majority of cases it is an auto-infection, and the lowered resistance due
to exposure or to alcohol, or a trauma or anaesthetization, simply furnishes
conditions which favor the spread and growth of a parasite already present.
Individuals who have already had pneumonia should be careful to keep the
teeth in good condition, and the mouth and throat in as healthy a state as pos-
sible. Antiseptic mouth washes may be used.
We know practically nothing of the conditions under which the pneumo-
coccus lives outside the body, or how it gains entrance in healthy individuals.
The sputum of each case should be very carefully disinfected. In institutions
the cases should be isolated.
Treatment. — Pneumonia is a self-limited disease, which can neither be
aborted nor cut short by any known means at our command. Even under
the most unfavorable circumstances it may terminate abruptly and naturally.
A patient was admitted to the Philadelphia Hospital on the evening of the
seventh day after the chill, in which he had been seen by one of my assistants,
who had ordered him to go to a hospital. He remained, however, in his house
190 SPECIFIC INFECTIOUS DISEASES.
alone, without assistance, taking nothing but a little milk and bread and
whisky, and was brought into the hospital by the police in a condition of
active delirium. That night his temperature was 105° and his pulse above
120. In his delirium he tried to escape through the window of the ward.
The following morning — the eighth day — the crisis occurred, and the tem-
perature was below 98°. The entire lower lobe of the right side was found
involved, and he entered upon a rapid convalescence. So also, under the
favoring circumstances of good nursing and careful diet, the experience of
many physicians in different lands has shown that pneumonia runs its course
in a definite time, terminating sometimes spontaneously on the third or the
fifth day, or continuing until the tenth or twelfth.
There is no specific treatment for pneumonia. The young practitioner
should bear in mind that patients are more often damaged than helped by
the promiscuous drugging, which is still only too prevalent.
1. General Managemext of a Case. — The same careful hygiene of the
bed and of the sick-room should be carried out as in typhoid fever. When
conditions are favorable the bed may be wheeled into the open air. The
patient should not be too much bundled up with clothing. For the heavy
flannel undershirts should be substituted a thin, light flannel jacket, open
in front, which enables the physician to make his examinations without unnec-
essarily disturbing the patient. The room should be bright and light, letting
in the sunshine if possible, and thoroughly well ventilated. Only one or two
persons should be allowed in the room at a time. Even when not called for
on account of the high fever, the patient should be carefully sponged each
day with tepid water. This should be done with as little disturbance as possi-
ble. Special care should be taken to keep the mouth and gums cleansed.
2. Diet. — Plain water, a pleasant table water, or lemonade should be
given freely. When the patient is delirious the water should be given at
fixed intervals. The food should be liquid, consisting chiefly of milk, either
alone or, better, mixed with food prepared from some one of the cereals, and
eggs, either soft boiled or raw.
3. Special Treatment. — Certain measures are believed to have an influ-
ence in arresting, controlling, or cutting short the disease. It is very diffi-
cult for the practitioner to arrive at satisfactory conclusions on this question
in a disease so singularly variable in its course. How natural, when on the
third or fourth day the crisis occurs and convalescence sets in, to attribute
the happy result to the effect of some special medication ! How easy to forget
that the same unexpected early recoveries occur under other conditions ! The
following are among the measures which may be helpful :
(a) Bleeding. — The reproach of Van Helmont, that " a bloody Moloch
presides in the chairs of medicine," can not be brought against this genera-
tion of physicians. Before Louis' iconoclastic paper on bleeding in pneu-
monia it would have been regarded as almost criminal to treat a case without
venesection. We employ it nowadays much more than we did a few years
ago, but more often late in the disease than early. To bleed at the very onset
in robust, healthy individuals in whom the disease sets in with great intensity
and high fever is, I believe, a good practice. I have seen instances in which
it was very beneficial in relieving the pain and the dyspnoea, reducing the
temperature, and allaying the cerebral symptoms.
LOBAR PNEUMONIA. 191
(&) Drugs.- — Certain drugs are credited with the power of reducing the
intensity and shortening the duration of the attack. Among them veratrum
viride still holds a place, doses of TTl ij-v of the tincture given every two hours.
Tartar emetic — a remedy which had great vogue some years ago — is now
very rarely employed. To a third drug, digitalis, has been attributed of late
great power in controlling the course of the disease. Petresco gives at one
time as much as from 4 to 12 grammes of the powdered leaves, and claims
that these colossal doses are specially efficacious in shortening the course of
the disease and diminishing the mortality.
(c) Antipneumococcic Serum. — Anders' recent analyses of the reported
cases do not give a very favorable' impression of the value of the sera at present
in use. More perhaps may be expected from the polyvalent serum of Eomer,
but even with it 4 of the 24 cases treated in Curschmann's clinic died
(Passler).
4, Symptomatic Teeatment. — (a) To relieve the Pain. — The stitch in
the side at onset, which is sometimes so agonizing, is best relieved by a hypo-
dermic injection of a quarter of a grain of morphia. When the pain is less
intense and diffuse over one side, the Paquelin cautery applied lightly is very
efficacious, or hot or cold applications may be tried. When the disease is
fairly established the pain is not, as a rule, distressing, except when the
patient coughs, and for this the Dover's powder may be used in 5-grain doses,
according to the patient's needs. Hot poultices, formerly so much in use, re-
lieve the pain, though not more than the cold applications. For children they
are often preferable.
(&) To combat the Toxcemia. — Until we have a specific, either drug or
the product of the bacteriological laboratory, which will safely and surely
neutralize the toxins of the disease, we must be content with measures which
promote the elimination of the poisons. Unfortunately, we know very little
of the channels by which they are got rid of, but on general principles we may
suppose them to be the skin, the kidneys, and the bowels. By the tepid or
the cold bath not only is the action of the skin promoted, but the vaso-motor
centres are stimulated. Abundance of water should be given to promote the
flow of urine, and the saline infusion seems to act helpfully in this way.
The bowels should be kept freely open by saline laxatives.
(c) The third and all-important indication in the treatment of pneu-
monia is to support the circulation. We can not at present separate the effects
of the fever from those of the toxins. It is possible, indeed, as some suppose,
that the fever itself may be beneficial. Undoubtedly, however, high and pro-
longed pyrexia is dangerous to the heart, and should be combated. For this
our most trusty weapon is hydrotherapy, which in pneumonia is used in sev-
eral different ways. The ice-bag to the affected side is one of the most con-
venient and serviceable. It allays the pain, reduces the fever slightly, and,
as a rule, the patient says he feels very much more comfortable. Broad, flat
ice-bags are now easily obtained for the purpose, and if these are not available
an ice poultice can be readily made, and by the use of oil-silk the clothing
and bedding of the patient can be protected from the water. Cold sponging is
the best form of hydrotherapy to employ as a routine measure. When done
limb by limb the patient is but little disturbed, and it is refreshing and bene-
ficial. With very pronounced nervous symptoms and persistent high tempera-
192 SPECIFIC INFECTIOUS DISEASES.
ture, or with hyperpyrexia, a cold bath of ten minutes' duration may be given.
Probably the very best effect of the hydrotherapy is in the stimulating effect
on the vaso-motor centres. The dusky skin, increasing cyanosis, increasing
shortness of breath, with signs of oedema of the lungs, and the rapid, small,
soft pulse, tell of a progressive lowering of the blood tension. Digitalin given
hypodermically in full doses, ^V ~ iV gr., and strychnine, ^--g-V gr., are the
most satisfactory drugs to support the blood pressure. Camphor and caffein
and musk are also of value. The effect of adrenalin, even in intravenous injec-
tion, is too transitory to be of any value. Alcohol does not seem to raise the
blood pressure in fever, and the studies of Briggs and Cook in my wards would
indicate that it is not of much value in progressive vaso-motor collapse. This
does not mean, however, that it may not have a value in the fever, and I
should be sorry to give up its use in the severer forms of enteric and of pneu-
monia. Saline infusions promote elimination and may help in tiding over
a, period of vascular depression. A litre may be allowed to run by gravity
beneath the skin, and if necessary may be repeated two or three times in the
twenty-four hours.
Oxygen Gas. — It is doubtful whether the inhalation of oxygen in pneu-
monia is really beneficial. The work of Lorrain-Smith suggests, indeed,
that it may under certain circumstances be positively harmful. He has shown
experimentally that oxygen may be a serious irritant, actually producing
inflammation of the lungs. If we are justified in applying his results to man,
there can be but little doubt that the administration of oxygen may not be
entirely " harmless," as stated in previous editions of this work. If the tension
of the oxygen breathed rises to 80 per cent of an atmosphere, which it might
•easily do in certain methods of administration, it may be injurious. When
used it should be allowed to flow gently from the nozzle held at a little dis-
tance, in which way it is freel}" diluted with air.
Treatment of Complications. — If the fever persists it is important to look
out for pleurisy, particularly for the meta-pneumonic empyema. The explora- .
tory needle should be used if necessary. A sero-fibrinous effusion should be
aspirated, a purulent opened and drained. In a complicating pericarditis with
a large effusion aspiration may be necessary. Delayed resolution is a difficult
condition to treat. Fibrotysin, 2.5 cc. every other day, has been used suc-
cessfully in a few cases (Crofton).
XVI. DIPHTHERIA.
Definition. — A specific infectious disease, characterized by a local fibrinous
exudate, usually upon a mucous membrane, and by constitutional symptoms
due to toxins produced at the site of the lesion. The presence of the Klebs-
Loefiler bacillus is the etiological criterion by which true diphtheria is distin-
guished from other forms of membranous inflammation.
The clinical and bacteriological conceptions of diphtheria are at present
not in full accord. On the one hand, there are cases of simple sore throat
which the bacteriologists, finding the Klebs-Loeffler bacillus, call true diph-
theria. On the other hand, cases of membranous, sloughing angina, diag-
nosed by the physician as diphtheria, are called by the bacteriologists, in
DIPHTHERIA. 193
the absence of the Klebs-Loeffler bacilkis, pseudo-diphtheria or diphtheroid
angina. The term diphtheroid may be used for the present to designate those
forms in which the Klebs-Loeffler bacillus is not present. Though usually
milder, severe constitutional disturbance, and even paralysis, may follow these
so-called pseudo-diphtheritic processes.
For an exhaustive discussion on every aspect of the disease the reader is
referred to the splendid monograph, edited by Nuttall and Graham- Smith,
Cambridge, 1908.
History. — Known in the East for centuries, and referred to in the Baby-
lonian Talmud, it is not until the first century a.d. that an accurate clinical
account appears in the writings of Aretseus. The paralysis of the palate was
recognized by ^tius (sixth century a.d.). Throat pestilences are mentioned
in the Middle Ages. Severe epidemics occurred in Europe in the sixteenth
and seventeenth centuries, particularly in Spain. In England in the latter part
of the eighteenth century it was described by Fothergill and Huxham, and in
America by Bard. Washington died of the disease. Ballonius recognized the
affection of the larynx and trachea in 1762, Home in Scotland described it
as croup. The modern description dates from Bretonneau, of Tours (1826),
who gave to it the name diphtherite. Throughout the nineteenth century it
prevailed extensively in all known countries, and it is at present everywhere
epidemic. After innumerable attempts, in which Klebs took a leading part,
the peculiar organism of the disease was isolated by Loeffler. The toxin was
next determined by the work of Eoux, Yersin, and others, and finally the anti-
toxin was discovered by Behring. As told by Loeffler in the above-mentioned
volume, the story is one of the most brilliant of the achievements of scientific
medicine.
Etiology. — Everywhere endemic in large centres of population the disease
becomes at times epidemic. It is more prevalent on the continent of Europe
than in Great Britain, and Ireland has less than other countries. The large
cities of the United States have been much afflicted, and wide-spread epidem-
ics have occurred in country districts. Pandemics occur cyclically, at irregu-
lar intervals, under conditions as yet imperfectly known. Dry seasons seem
to favor the disease, which, like typhoid fever, shows an autumnal prevalence.
Modes of Infection. — The disease is highly contagious. The bacilli may be
transmitted (a) from one person to another; few diseases have proved more
fatal to physicians and nurses. (&) Infected articles may convey the bacilli,
which may remain alive for many months; scores of well-attested instances
have been recorded of this mode of transmission, (c) Persons suffering from
atypical forms of diphtheria may convey the disease; nasal catarrh, mem-
branous rhinitis, mild tonsillitis, otorrhoea may be caused by the diphtheria
bacilli, and from each of these sources cases have been traced, (d) From the
throats of healthy contacts — diphtheria carriers, persons who present no signs
of the disease, the bacilli have been obtained by culture; instances of this
method have multiplied of late in the literature, and a list is given by Graham-
Smith, (e) Even healthy children without any naso-pharyngeal catarrh,
who have not been in contact with the disease, may in large cities harbor
the bacilli. In 1,000 children' from the New York tenements Sholley found
18 with virulent and 38 with non-virulent bacilli. Long after recovery has
taken place virulent bacilli have been isolated from the throat. It is impor-
14
194 SPECIFIC INFECTIOUS DISEASES.
tant to bear in mind under d and e that it is only persons wlio harbor the
virulent forms who are capable of transmitting the disease. In schools the
interchange of articles, such as sweets, pencils, etc., and the habit which
children have of putting ever3rthing into their mouths afford endless oppor-
tunities for the transmission of the disease. As Westbrook remarks, diph-
theria is transmitted usually by almost direct exchange of the flora of the
nose and mouth. (/) Numerous epidemics have been traced to milk, since
Power in 1878 determined this method of spread. Virulent bacilli have been
found in the milk, and Dean and Todd and Ashby have found virulent organ-
isms in the acquired lesions on the teats of cows, (g) A few instances of
accidental infection from cultures and through animals are on record.
Air borne infections, through sewer gas, soil, drains, dust, etc., are not
now held to occur. The disease may be transmitted by direct inoculation.
Predisposing Causes. — Age is the most important. Sucklings are not often
attacked, but Jacobi saw three eases in the new-born. Early in the second
year the disposition increases rapidly, and continues at its height until the
fifth year. At Baginsky's clinic, Berlin, among 2,711 cases, 1,235 occurred
from the second to the fifth years inclusive. In ISTew York between 1891-1900
among the deaths 80.8 per cent occurred under five, 17 per cent l^etween five
and ten — figures which show the extraordinary preponderance of the disease
among children. Girls are attacked in slightly larger numbers than boys.
November, December, and January are the months of greatest prevalence in
the United States; in London the months of October and November.
Soil and altitude have little or no influence on the prevalence of the dis-
ease; nor does race play an important role. Individiial susceptibility is a
very special factor; not only do very many of those exj)Osed escape, but even
those, too, in whose throats virulent bacilli lodge and grow.
The Klebs-Loeffler bacillus occurs in a large number of all suspected cases
— 72 per cent, based upon an analysis of 27,000 cases in the literature by
Graham Smith. It is found chiefly in the false membrane, and does not
extend into the subjacent mucosa. In the majority of instances the organ-
isms are localized, and only a few penetrate into the interior. Post mortem
in many instances the bacilli are found in the blood and in the internal
organs. Occasionally they are found in the blood during life. It may be the
predominating or sole organism in the broncho-pneumonia so common in
the disease. Outside the throat, the common site of its morbid action, the
Klebs-Loeffler bacillus has been found in diphtheritic conjunctivitis, in otitis
media, sometimes in wound diphtheria, upon the genitals, in fibrinous rhi-
nitis, and in an attenuated condition by Howard in a case of ulcerative
endocarditis.
Morphological Characters. — The bacillus is non-motile, varies from
2.5 to 3 ju, in length and from 0.5 to 0.8 [x in thickness. In appearance it is
multiform, varying from short rather sharply pointed rods to irregular bizarre
forms, with one or both ends swollen, and staining more or less unevenly
and intensely. Westbrook recognizes three main types — granular, barred, and
solid staining. Branching forms are occasionally met with. The bacillus
stains in sections or on the cover-glass by the Gram method.
It grows best upon a mixture of glucose bouillon and blood serum
(Loeffler), forming moderate-sized, elevated, grayish-white colonies with
DIPHTHERIA. 195
opaque centres. It grows also upon all the ordinary culture media. The
growth usually ceases at temperatures below 20° C.
The bacillus is very resistant, and cultures have been made from a bit of
membrane preserved for five months in a dry cloth. Incorporated with dust
and kept moist, the bacilli were still cultivable at the end of eight weeks;
kept in a dried state they no longer grew at the end of this period (Ritter).
Variation in Virulence. — The Klebs-Loeffler bacillus evidently has very
varying grades of virulence down even to complete absence of pathogenic
effects. The name pseudo-bacillus of diphtheria should not be given to
this avirulent organism. For testing the virulence the guinea-pig is used,
being most susceptible to the poison. For a gross test an amount of a
forty-eight-hour bouillon culture equalling one-half per cent of the weight
of the animal is injected subcutaneously. Park and Williams obtained a
bacillus of such extraordinary virulence that 0.005 cc. of a filtered bouillon
culture killed a 500 gramme guinea-pig in seventy-two hours. " A fully
virulent culture is one which causes the death of a guinea-pig within three
days or less; a culture of medium virulence one which causes the death of
the animal in from three to five days. Cultures which only produce local
necrosis and ulceration or death after a greater number of days may be con-
sidered as of slight virulence" (J. H. Wright). At the seat of the inocula-
tion there is local necrosis with fibrinous exudate which contains the bacilli,
and there is also a more or less extensive cedema of the subcutaneous tissue.
The Presence of the Klees-Loefeler Bacillus in Non-membranous
Angina and in Healthy Throats. — The bacillus has been isolated from
cases which show nothing more than a simple catarrhal angina, of a mild type
without any membrane, with diffuse redness, and perhaps huskiness and signs
of catarrhal laryngitis. In other cases the anatomical picture may be that of
a lacunar tonsillitis.
The organisms may be met with in perfectly healthy throats, particularly
in persons in the same house, or the ward attendants and nurses in fever
hospitals.
Following an attack of diphtheria the bacilli may persist in the throat or
nose after all the membrane has disappeared for weeks or months — even 15
months. In explanation of this persistence Councilman has called attention
to the frequency with which the antrum is affected.
Toxin op the Klebs-Loeffler Bacillus. — Roux and Yersin showed
that a fatal result following the inoculation with the bacillus was not caused
by any extension of the micro-organisms within the body; and they were
enabled in bouillon cultures to separate the bacilli from the poison. The toxin
so separated killed with very much the same effects as those caused by the
inoculation of the bacilli; the pseudo-membrane, however, is not formed.
These results were confirmed by many observers, particularly by Sidney Mar-
tin, who separated a toxic albumose. The precise composition of the body
and whether it is a proteid at all is still doubtful; certain authorities, how-
ever, believe that it belongs to the enzymes, possessing as it does many attri-
butes in common with them.
Susceptible animals may be rendered immune from diphtheritic infection
by injecting weakened cultures of the bacillus or, what is better, suitable doses
of the diphtheria toxin. The result of the injections is a febrile reaction
196 SPECIFIC INFECTIOUS DISEASES.
which soon passes away and leaves the animal less susceptible to the poison or
the living bacilli. By repeating and gradually increasing the quantity of
poison injected a high degree of immunity can be produced in large animals
(goat, horse).
The Bacteria associated with the Diphtheria Bacillus. — The most
common is the streptococcus pyogenes. Otliers, in addition to the organisms
constantly found in the mouth, are the micrococcus lanceolatus, the bacillus
coli, and the staphylococcus aureus and albus. Of these, probably the strepto-
coccus pyogenes is the most important, as cases of general infection with this
organism have been found in diphtheria. The suppuration in the lymph-
glands and the broncho-pneumonia are usually (though not always) caused by
this organism.
Pseudo-Diphtheeia Bacillus. — BaciUus Xerosis. — As mentioned above,
the Ellebs-Loeffler bacillus varies very much in its virulence, and it exists in a
form entirely devoid of pathogenic properties. This organism should not,
however, be designated pseudo-diphtheria bacillus. The name should be con-
fined to bacilli, which, though resembling the diphtheria bacillus, differ from
it not only by absence of virulence, but also by cultured peculiarities. A
similar bacillus, showing, however, certain cultural differences from the
pseudo-diphtheria bacillus, has been repeatedly found in the conjunctival sac
in health and disease (B. xerosis). Organisms having the morphology of
the dif)htheria bacillus, but devoid of virulence, probably belonging to the
group of pseudo-diphtheria and xerosis bacilli, have been described in human
beings in association with a number of diseases, such, as Eg}'ptian dysentery
(Kruse and Pasquale) ; they have been demonstrated upon the skin, in the
crusts of variola pustules, and in impetigo, in sputum, in pneumonia (Kruse,
Olilmacher), in gangi-ene of the lung (Babes), in ulcerative endocarditis
(Howard), in ascitic fluid (Harris), in pus from pyuria (Bergey), in. ozsna
(Wilder), and in tuberculosis (Schiiltz and Ehret). Other varieties of
pseudo-bacillus, described b}' Euediger and Alice Hamilton, possess a virulence
sufficient to cause severe lesions in man and death in inoculated animals. In
such cases the antitoxin had no influence on the infection, but animals recov-
ered upon the injection of an immune serum prepared from these bacilli.
Diphtheroid Inflammations. — Under the term diphtheroid may be grouped
those membranous inflammations which are not associated with the Klebs-
Loeffier bacillus. It is perhaps a more suitable designation than pseudo-diph-
theria or secondary diphtheria. As in a great majorit}'' of cases the strepto-
coccus pyogenes is the active organism, the term " streptococcus diphtheritis "
is often employed. The name " diphtheritis *' is best used in an anatomical
sense to designate an inflammation of a mucous membrane or integumentary
surface characterized by necrosis and a fibrinous exudate, whereas the term
" diphtheria " should be limited to the disease caused by the Klebs-LoeSier
bacillus. The proportion of cases of diphtheroid inflammation varies greatly
in the different statistics. Of the large number of observations made by Park
and Beebe (5,611) in oSTew York, 40 per cent were diphtheroid. Figures from
other sources do not show so high a percentage.
It is not to be inferred from these statistics that any considerable number
of the cases which present the appearances of typical and characteristic pri-
mary diphtheria are due to other micro-organisms than the Klebs-Loeffler
DIPHTHERIA. 197
bacillus. Nearly all such cases, when carefully examined by a competent bac-
teriologist, are found to be due to the diphtheria bacillus. It is the less char-
acteristic cases, with more or less suspicion of diphtheria, which are most
likely to be caused by other bacteria than the Klebs-Loeffler bacillus. It is
also to be remembered that in the routine examination of a large number of
cases for boards of health and diphtheria wards of hospitals, some cases of
genuine diphtheria may escape recognition from lack of such repeated and
thorough bacteriological tests as are sometimes required for the detection of
cases presenting unusual difficulties.
Conditions under which the Diphtheroid Affection occurs. — Of
450 cases (Park and Beebe), 300 occurred in the autumn months and 150 in
the spring; 198 occurred in children from the first to the seventh year. In a
large proportion of all the cases the disease develops in children, and can be
differentiated from diphtheria proper only by the bacteriological examination.
In many of the cases it is simply an acute catarrhal angina with lacunar ton-
sillitis.
The diphtheroid inflammations are particularly prone to develop in connec-
tion with the acute fevers.
(a) Scarlet Fever. — In a large proportion of the cases of angina in scar-
let fever the Klebs-Loeffler bacillus is not present. Booker has reported 11
cases complicating scarlet fever, in all of which the streptococci were the pre-
dominant organisms. Of the 450 cases of Park and Beebe, 43 complicated
scarlet fever. The angina of this disease is not always, however, due to the
streptococcus. Where diphtheria is prevalent and opportunities are favorable
for exposure, a large proportion of the cases of membranous throats in scarlet
fever may be genuine diphtheria, as is shown by the statistics of Williams and
Morse in the Boston City Hospital. Here, of 97 cases of scarlet fever, mem-
branous angina was present in 35 ; in 12 with the Klebs-Loeffler bacillus, and
in 23 with other organisms. Morse reports 99 cases of angina in scarlet fever
in which 76 were diphtheritic. This large proportion of cases in which scar-
let fever was associated with true diphtheria is attributed to local conditions
in the hospital.
(&) Measles. — Membranous angina is much less common in this disease.
It occurred in 6 of the 450 diphtheroid cases in New York. Of 4 cases with
severe membranous angina at the Boston City Hospital, 1 only presented the
Klebs-Loeffler bacillus.
(c) Whooping-cough may also be complicated with membranous angina.
The bacteriological examinations have not been very numerous, Escherich
gives 4 cases, in all of which the Klebs-Loeffler bacillus was found.
(d) Typhoid Fever. — Membranous inflammations in this disease are not
very infrequent; they may occur in the throat, the pelvis of the kidney, the
bladder, or the intestines. The complication may be caused by the Klebs-Loef-
fler bacillus, which was present in 4 eases described by Morse. It is frequently,
however, a streptococcus infection.
Ernst Wagner has remarked upon the greater frequency of these mem-
branous inflammations in typhoid fever when diphtheria is prevailing.
Clinical Features of the Diphtheroid Affection. — The- cases, as a rule, are
milder, and the mortality is low, only 2.5 per cent in the 450 cases of Park
and Beebe. The diphtheroid inflammations complicating the specific fevers
198 SPECIFIC INFECTIOUS DISEASES.
are, however, often very fatal, and a general streptococcus infection is by no
means infrequent. As in the Klebs-Loeffler angina, there may be only a simple
catarrhal process. In other instances the tonsils are covered with a creamy,
pultaceous exudate, without any actual membrane. An important group may
begin as a simple lacunar tonsillitis, while in others the entire fauces and ton-
sils are covered by a continuous membrane, and there is a foul sloughing
angina with intense constitutional disturbance.
Are the diphtheroid cases contagious? General clinical experience war-
rants the statement that the membranous angina associated with the fevers
is rarely communicated to other patients. The health department of New
York does not keep the diphtheroid cases under supervision. Their inves-
tigation of the 450 diphtheroid cases seems to justify this conclusion. Park
and Beebe say that " it did not seem that the secondary cases were any less
liable to occur when the primary case was isolated than when it was not.'^
SequelcB of the Diphtheroid Angina. — The usual mildness of the disease
is in part, no doubt, due to the less frequent systemic invasion. Some of the
worst forms of general streptococcus infection are, however, seen in this dis-
ease. There are no peculiarities, local or general, which can be in any way
regarded as distinctive; and even the most extensive paralysis may follow an
angina caused by it.
Morbid Anatomy. — Distribution op Membrane. — A definite membrane
was found in 127 of the 220 fatal Boston cases, distributed as follows : tonsils,
65 cases; epiglottis, 60; larynx, 75; trachea, 66; pharynx, 51; mucous mem-
brane of nares, 43; bronchi, 42; soft palate, including uvula, 13; oesophagus,
12; tongue, 9; stomach, 5; duodenum, 1; vagina, 2; vulva, 1; skin of ear, 1;
conjunctiva, 1. An interesting point in the Boston investigation was the great
frequency with which the accessory sinuses of the nose were found to be in-
fected. In the fatal cases, the exudation is very extensive, involving the uvula,
the soft palate, the posterior nares, and the lateral and posterior walls of the
pharynx. These parts are covered with a dense pseudo-membrane, in places
firmly adherent, in others beginning to separate. In extreme cases the necro-
sis is advanced and there is a gangrenous condition of the parts. The mem-
brane is of a dirty greenish or gray color, and the tonsils and palate may be in
a state of necrotic sloughing. The erosion may be deep enough in the tonsils
to open the carotid artery, or a false aneurism may be produced in the deep
tissues of the neck. The nose may be completely blocked by the false mem-
brane, which may also extend into the conjunctivae and through the Eusta-
chian tubes into the middle ear. In cases of laryngeal diphtheria the exudate
in the pharynx may be extensive. In many cases, however, it is slight upon
the tonsils and fauces and abundant upon the epiglottis and the larynx, which
may be completely occluded by false membrane. In severe cases the exudate
extends into the trachea and to the bronchi of the third or fourth dimension.
In all these situations the membrane varies very much in consistence,
depending greatly upon the stage at which death has taken place. If death
has occurred early, it is firm and closely adherent ; if late, it is soft, shreddy,
and readily detached. When firmly adherent it is torn ofE with difficulty and
leaves an abraded mucosa. In the most extreme cases, in which there is exten-
sive necrosis, the parts look gangrenous. In fatal cases the lymphatic glands
of the neck are enlarged, and there is a general infiltration of the tissues with
DIPHTHERIA. 199
serum; the salivary glands, too, may be swollen. In rare instances the mem-
brane extends to the gullet and stomach.
On inspection of the larynx of a child dead of membranous croup the rima
is seen filled with mucus or with a shreddy material which, when washed off
carefully, leaves the mucosa covered by a thin grayish-yellow membrane, which
may be uniform or in patches. It covers the ary-epiglottic folds and the true
cords, and may be continued into the ventricles or even into the trachea.
Above, it may involve the epiglottis. It varies much in consistency. I have
seen fatal cases in which the exudation was not actually membranous, but
rather friable and granular. It may form a thick, even stratified membrane,
which fills the entire glottis. The exudation may extend down the trachea
and into the bronchi, and may pass beyond the epiglottis to the fauces. Usu-
ally it is readily stripped off from the mucous membrane of the larynx and
leaves exposed the swollen and injected mucosa. On examination it is seen
that the fibrinous material has involved chiefly the epithelial lining and has not
greatly infiltrated the subjacent tissues.
We owe largely to the labors of Wagner, Weigert, and more particularly to
the splendid work of Oertel, our knowledge of the histological changes which
take place in diphtheria. The beginning of the lesion is due to the toxic action
of the bacilli growing in the throat. The primary lesion is a necrosis and
degeneration of the epithelial tissues. The organisms grow, not in the living,
but in the necrotic tissues. The first step is necrosis of the epithelium, often
preceded by active proliferation of the nuclei of the cells, which become
changed into refractive hyaline masses. From the structures below an inflam-
matory exudate rich in fibrin factors is poured out, and fibrin is formed when
this comes in contact with the necrotic epithelium.
The following are the important changes in the other organs :
Heart. — Fatty degeneration is found in a majority of the cases. It may
precede the more advanced degeneration, in which tjie sarcous elements become
swollen and converted into hyaline masses. There is a primary, acute, inter-
stitial myositis, and also a form secondary to degeneration of the heart muscle,
to which it is possible that some of the cases of fibrous myocarditis are due.
Pericarditis and endocarditis are rare; endocarditis was present in 7 of 220
cases at the Boston City Hospital. The diphtheria bacilli have been found in
the vegetations.
The PULMONARY COMPLICATIONS are the most important, and death is due
to them as often as to the throat lesion. Broncho-pneumonia, or, as Council-
man terms it, 'acinous pneumonia, is the most common, and was present in 131
of the 220 Boston cases. Acute lobar pneumonia is rare. The pneumococcus
is the principal agent in producing the lung infection. The streptococci and
the diphtheria bacilli are frequently met with.
Kidneys. — The lesions, which are due to the action of the toxins, not to
the presence of bacteria, vary from simple degeneration to an intense nephritis.
There is no specific type of lesion. Interstitial and glomerular nephritis are
most common in the older subjects. Degenerative changes are present in a
large proportion of all the fatal cases.
The liver and the spleen show the degenerative lesions of the acute
infections.
General infection is common, and is about equal with the streptococcus and
200 SPECIFIC INFECTIOUS DISEASES.
the diphtheria bacillus. It occurs generally in the grave septic cases, in which
type of cases the former organism is more frequently met with.
Symptoms. — The period of incubation is " from two to seven days, often-
est two."
The initial symptoms are those of an ordinary febrile attack — slight chilli-
ness, fever, and aching pains in the back and limbs. In mild cases these symp-
toms are trifling, and the child may not feel ill enough to go to bed. Usually
the temperature rises within the first twenty-four hours to 102.5° or 103°; in
severe cases to 101:°. In young children there may be convulsions at the
outset.
Phaetxgeal Diphtheria. — In a typical case there is at first redness of
the fauces, and the child complains of slight difficulty in swallowing. The
membrane first appears upon the tonsils, and it may be a little difficult to dis-
tinguish a patchy diphtheritic pellicle from the exudate of the tonsillar crypts.
The phar}Tigeal mucous membrane is reddened, and the tonsils themselves are
swollen. By the third day the membrane has covered the tonsils, the pillars of
the fauces, and perhaps the uvula, which is thickened and oedematous, and
may fill completely the space between the swollen tonsils. The membrane may
extend to the posterior wall of the phar}Tix. At first grajdsh-white in color,
it changes to a dirty gray, often to a yellow-white. It is firmly adherent, and
when removed leaves a bleeding, slightly eroded surface, which is soon covered
by fresh exudate. The glands in the neck are swollen, and may be tender.
The general condition of a patient in a case of moderate severity is usually
good; the temperature not very high, in the absence of complications ranging
from 102° to 103°. The pulse^range is from 100 to 120. The local condition
of the throat is not of great severity, and the constitutional depression is slight.
The symptoms gradually abate, the swelling of the neck diminishes, the mem-
branes separate, and from the seventh to the tenth day the throat becomes clear
and convalescence sets in.
Clinically at^^ical forms are extremely common, and I follow here Koplik's
division :
(a) There may be no local manifestation of membrane, but a simple catar-
rhal angina associated sometimes A^itli a croupy cough. The detection in these
cases of the Klebs-Loeffler bacillus can alone determine the diagnosis. Such
cases are of great moment, inasmuch as they may communicate the severer
disease to other children.
(6) There are cases in which the tonsils are covered by a pultaceous exu-
date, not a consistent membrane.
(c) Cases presenting a punctate form of membrane, isolated, and usually
on the surface of the tonsils.
(d) Cases which begin and often run their entire course with the local
picture of a typical lacunar amygdalitis. The}' may be mild, and the local
exudate may not extend, but in other cases there are rapid development of
membrane, and extension of the disease to the phar}Tix and the nose, with
severe septic and constitutional symptoms.
(e) Under the term '^latent diiDhtheria " Heubner has described eases,
usually secondary, occurring chiefly in hospital practice, in young persons the
subject of wasting affections, such as rickets and tuberculosis. There are fever,
naso-jDhar^-ngeal catarrh, and gastro-intestinal disturbances. Diphtheria may
DIPHTHERIA. 201
not be suspected until severe laryngeal complications develop, or the condition
may not be determined until autopsy.
Systemic Infection. — The constitutional disturbance in mild diphtheria
is very slight. There are instances, too, of extensive local disease without
grave systemic symptoms. As a rule, the general features of a case bear a
definite relation to the severity of the local disease. There are rare instances
in which from the outset the constitutional prostration is extreme, the pulse
frequent and small, the fever high, and the nervous phenomena are pro-
nounced ; the patient may sink in two or three days overwhelmed by the inten-
sity of the toxaemia. There are cases of this sort in which the exudate in the
throat may be slight, but usually the nasal symptoms are pronounced. The
temperature may be very slightly raised or even subnormal. More commonly
the severe systemic symptoms appear at a later date when the pharyngeal lesion
is at its height. They are constantly present in extensive disease, and when
there is a sloughing, foetid condition. The lymphatic glands become greatly
enlarged; the pallor is extreme; the face has an ashen-gray hue; the pulse
is rapid and feeble, and the temperature sinks below normal. In the most
aggravated forms there are gangrenous processes in the throat, and in rare
instances, when life is prolonged, extensive sloughing of the tissues of the neck.
Escherich accounts for the discrepancy sometimes observed between the
severity of the constitutional disturbance and the intensity of the local process,
by assuming varying degrees of susceptibility to the diphtheria bacillus on the
one hand, and to its poison on the other hand. With high local susceptibility
of a part to the action of the bacillus, with little general susceptibility to the
toxin, there is extensive local exudate with mild constitutional symptoms, or
vice versa, severe systemic disturbance with limited local inflammation.
A leucocytosis is present in diphtheria. Morse does not think it of any
prognostic value, since it is present and may be pronounced in mild cases.
What has been described of late as Vincent's angina is an acute, febrile,
pseudo-membranous inflammation with soft, yellowish-green exudate, which
on removal leaves a bleeding ulcer. The general symptoms may be severe, and
there may be swelling of the glands of the neck. A bacillus f usif ormis has been
described in connection with it. There are instances in which the ulceration
has been extensive, even proceeding to destruction of the uvula and of the soft
palate.
Nasal Diphtheria. — In cases of pharyngeal diphtheria the Klebs-Loef-
fler bacillus is found on the mucous membrane of the nose and in the secre-
tions, even when no membrane is present, but it may apparently produce two
affections similar enough locally but widely differing in their general features.
In membranous or fibrinous rJiinitis, a very remarkable affection seen usu-
ally in children, the nares are occupied by thick membranes, but there is an
entire absence of any constitutional disturbance. The condition has been stud-
ied very carefully by Park, Abbott, Gerber and Podack, and others. Eavenel
has collected 77 cases, in 41 of which a bacteriological examination was made,
in 33 the Klebs-Loeffler bacillus being present. All the cases ran a benign
course, and in all but a few the membrane was limited to the nose, and the
constitutional symptoms were either absent or very slight. Eemarkable and
puzzling features are that the disease runs a benign course, and that infection
of other children in the family is extremely rare.
15
202 SPECIFIC INFECTIOUS DISEASES.
On the other hand, nasal diphtheria is apt to present a most malignant
type of the disease. The infection may be primary in the nose, and in a case
in my wards there was otitis media, and the Klebs-Loeffler bacillus was sepa-
rated from the discharge before the condition of nasal diphtheria was sus-
pected. While some cases are of mild character, others are very intense, and
the constitutional symptoms most profound. The glandular inflammation is
usually very intense, owing, as Jacobi points out, to the great richness of the
nasal mucosa in lymphatics. From the nose the inflammation may extend
through the tear-ducts to the conjunctivae and into the antra.
Laryngeal Diphtheria. — Membranous Group. — ^With a very large pro-
portion of all the cases of membranous laryngitis the Klebs-Loeffler bacillus is
associated ; in a much smaller number other organisms, particularly the strep-
tococcus, are found. Membranous croup, then, may be said to be either genu-
ine diphtheria or diphtheroid in character. Of 286 cases in which the disease
was confined to the larynx or bronchi, in 229 the Klebs-Loeffler bacilli were
found. In 57 they were not present, but 17 of these cultures were unsatis-
factory (Park and Beebe). The streptococcus cases are more likely to be sec-
ondary to other acute diseases.
Symptoms. — Naturally, the clinical symptoms are almost identical in the
non-specific and specific forms of membranous larjTigitis.
The affection begins like an acute laryngitis with slight hoarseness and
rough cough, to which the term croupy has been applied. After these symp-
toms have lasted for a day or two with varying intensity, the child suddenly
becomes worse, usually at night, and there are signs of impeded respiration.
At first the difficulty in breathing is paroxysmal, due probably to more or less
spasm of the muscles of the glottis. Soon the dyspncea becomes continuous,
inspiration and expiration become difficult, particularly the latter, and with
the inspiratory movements the epigastrium and lower intercostal spaces are
retracted. The voice is husky and may be reduced to a whisper. The color
gradually changes and the imperfect aeration of the blood is shown in the
lividity of the lips and finger-tips. Restlessness comes on and the child tosses
from side to side, vainly trying to get breath. Occasionally, in a severer par-
oxysm, portions of membrane are coughed out. The fever in membranous
laryngitis is rarely very high and the condition of the child is usually very
good at the time of the onset. The pulse is always increased in frequency and
if cyanosis be present is small. In favorable cases the dyspnoea is not very
urgent, the color of the face remains good, and after one or two paroxysms the
child goes to sleep and wakes in the morning, perhaps without fever and feel-
ing comfortable. The attack may recur the following night with greater
severity. In unfavorable cases the dyspnoea becomes more and more urgent,
the cyanosis deepens, the child, after a period of intense restlessness, sinks into
a semi-comatose state, and death finally occurs from poisoning of the nerve
centres by carbon dioxide. In other cases the onset is less sudden and is pre-
ceded by a longer period of indisposition. As a rule, there are pharyngeal
symptoms. The constitutional disturbance may be more severe, the fever
higher, and there may be swelling of the glands of the neck. Inspection of
the fauces may show the presence of false membranes on the pillars or on the
tonsils. Bacteriological examination can alone determine whether these are
due to the Klebs-Loeffler bacillus or to the streptococcus. Fagge held that non-
DIPHTHERIA. 203
contagious membranous croup may spread upward from the larynx just as
diphtheritic inflammation is in the habit of spreading downward from the
fauces. Ware, of Boston, whose essay on croup is perhaps the most solid con-
tribution to the subject made in this country, reported the presence of exudate
in the fauces in 74 out of 75 cases of croup. These observations were made
prior to 1840, during periods in which diphtheria was not epidemic to any
extent in Boston. In protracted cases pulmonary symptoms may occur, which
are sometimes due to the difficulty in expelling the muco-pus from the tubes ;
in others, the false membrane extends into the trachea and even into the
bronchial tubes. During the paroxysm the vesicular murmur is scarcely audi-
ble, but the laryngeal stridor may be loudly communicated along the bronchial
tubes.
DiPHTHKRiA OF Other Parts. — Primary diphtheria occurs occasionally
in the conjunctiva. It follows in some instances the affection of the nasal
mucous membrane. Some of the cases are severe and serious, but it has been
shown by C. Frankel and others that the diphtheria bacilli may be present in
a conjunctivitis catarrhal in character, or associated with only slight croupous
deposits.
Diphtheria of the external auditory meatus is seen in rare instances in
which a diphtheritic otitis media has extended through the tympanic mem-
brane.
Diphtheria of the shin is most frequently seen in the severer forms of
pharyngeal diphtheria, in which the membrane extends to the mouth and
lips, and invades the adjacent portions of the skin of the face. The skin about
the anus and genitals may also be attacked. Pseudo-membranous inflamma-
tion is not uncommon on ulcerated surfaces and wounds. In very many
of these cases it is a streptococcus infection, but in a majority, perhaps,
in which the patient is suffering with diphtheria, the Klebs-Loeflier bacil-
lus will be found in the fibrinous exudate. As proposed by Welch, the term
"wound diphtheria" should be limited to infection of a wound by the
Klebs-Loeffler bacillus. This " may manifest itself as a simple inflamma-
tion, or inflammation with superficial necrosis, or inflammation with more or
less adherent pseudo-membrane. The conditions as regards varying intensity
and character of the infection, association with other bacteria, particularly
streptococci, and the necessity of a bacteriological examination to establish
the diagnosis, are in no way different in the diphtheria of wounds from those
in diphtheria of mucous membranes. Wound diphtheria may occur without
demonstrable connection with cases of diphtheria and without affection of the
throat in the individual attacked, but such occurrences are rare" (Welch).
Paralysis may follow wound diphtheria. Pseudo-membranous inflammations
of wounds are caused more frequently by other micro-organisms, particularly
the streptococcus pyogenes, than by the Klebs-Loefller bacillus. The fibrinous
membrane so common in the neighborhood of the tracheotomy wound in diph-
theria is rarely associated with the Klebs-Loeffler bacillus. Diphtheria of the
genitals is occasionally seen.
Complications and Sequelae. — Of local complications, hsemorrhage from
the nose or throat may occur in the severe ulcerative cases. Skin rashes are
not infrequent, particularly the diffuse erythema. Occasionally there is urti-
caria and in the severe cases purpura. Fatal cases almost invariably show
204 SPECIFIC INFECTIOUS DISEASES.
capillary bronchitis with broncho-pnemnonia and large patches of collapse, or
the septic particles may reach the bronchi and excite gangrenous processes
which may lead to severe and fatal hemorrhage. Jaundice, usually a feature
of the toxsemia is rarely of serious import.
Albuminuria, present in all severe cases, is alarming only when the albu-
min is in considerable quantity and associated with epithelial or blood casts.
Kepliritis may appear quite early in the disease, setting in occasionally with
complete suppression of the urine. In comparison with scarlet fever the renal
changes lead less frequently to general dropsy. In rare instances there may
be coma, and even convulsions, without albumin in the urine, and without
dropsy.
Of the sequelse, paralysis is by far the most important. It can be experi-
mentally produced in animals by the inoculation of the toxins. The disease is
a toxic neuritis, due to the absorption of the poison. The proportion of the
cases in which it occurs ranges from 10 to 15 and even to 20 per cent. It is
strictly a sequel, coming on usually in the second or third week of convales-
cence. It may follow very mild cases ; indeed, the local lesion may be so trifling
that the onset of the paralysis alone calls attention to the true nature of the
trouble. It is proportionately less frequent in children than in adults. L. W.
Eolleston's recent study of the subject indicates that the early use of anti-
toxin diminishes the liability to paralysis. In 494 cases collected by Wood-
head, the palate was involved in 155, the ocular muscles in 197, in 10 other
muscles. Ninety-one of the patients died.
Of the local paralyses the most common is that which affects the palate.
This gives a nasal character to the voice, and, owing to a return of liquids
through the nose, causes a difficulty in swallowing. The palate is seen to be
relaxed and motionless, and the sensation in it is also much impaired. The
affection may extend to the constrictors of the pharynx, and deglutition become
embarrassed. Within two or three weeks or even a shorter time the paralysis
disappears. In many cases the affection of the palate is only part of a general
neuritis. Of other local forms perhaps the most common are paralyses of the
eye-muscles, intrinsic and extrinsic. There may be strabismus, ptosis, and
loss of power of accommodation. Facial paralysis is rare. The neuritis may
be confined to the nerves of one limb, though more commonly the legs or the
arms are affected together. Very often with the palatal parah^sis is associated
a weakness of the legs without definite palsy but with loss of the knee-jerk.
The multiple form of diphtheritic neuritis may begin with the palatal
affection, or with loss of power of accommodation and loss of the tendon
reflexes. This last is an important sign, which, as Bernhardt, Buzzard, and
E. L. MacDonnell have sho^vn, may occur early, but is not necessarily fol-
lowed by other symptoms of neuritis. There is paraplegia, which may be
complete or involve only the extensors of the feet. The paralysis may extend
and involve the arms and face and render the patient entirely helpless. The
muscles of respiration may be spared.
Heart. — Irregularity of the heart is common. It was present in 60 per cent
of the Boston cases of White and Smith. A murmur at the apex or base of
the heart is present in 94 per cent of all cases. This means of course that a
majority of all young children with fever have a heart murmur. Only a few
cases of diphtheria have serious heart symptoms, 36 out of the 946 cases spe-
DIPHTHERIA. 205
ciall}^ studied. Eaj^id action of the heart with gallop rhythm and epigastric
pain and tenderness are the most serious symptoms. The cases in which the
pulse drops from 110 to 40 or 30 are usually very serious. The heart symp-
toms are more common in the second or third week of the disease, and fatal
dilatation of the heart may come on as late as the sixth or seventh week. It
seems probable that the heart weakness is due to granular and fatty degen-
eration of the muscle substance. Possibly in some of the cases there is degen-
eration of the vagus, a view which is supported by the frequency of paralysis
of the palate with vomiting and epigastric pain and tenderness.
Serum Sickness. — Strictly an effect of the treatment, " Die Serumkrank-
heit " may be considered among the complications. In from eight to ten days
after the inoculation there appears at the site an erythema or urticaria,
which spreads rapidly over the body. There is usually oedema, local glandular
enlargements, and in some cases albuminuria. There are pains and slight
swelling in the joints, and moderate fever. The oedema and the morbilli-
form and exudative rashes are the most striking features. Convalescence
occurs on the third or fourth day. These symptoms have been shown to be
due to the toxic effects of the horse serum.
Sudden death has occurred in about 20 cases after the serum injections
(Eosenau and Anderson). The serious symptoms come on within five or ten
minutes of the injection with collapse, unconsciousness, and convulsions and
death. The toxic effect is due to the alien serum, from which it is quite
possible that before long the dangerous elements may be removed.
Diagnosis. — The presence of the Klebs-Loeffler bacillus is regarded by bac-
teriologists as the sole criterion of true diphtheria, and as this organism may
be associated with all grades of throat affections, from a simple catarrh to a
sloughing, gangrenous process, it is evident that in many instances there will
be a striking discrepancy between the clinical and the bacteriological diagnosis.
The bacteriological diagnosis is simple. The plan adopted by the New
York Health Department is a model which may be followed with advantage in
other cities. Outfits for making cultures, consisting of a box containing a
tube of blood-serum and a sterilized swab in a test-tube, are distributed to
about forty stations at convenient points in the city. A list . of these places
is published, and a physician can obtain the outfit free of cost. The direc-
tions are as follows : " The patient should be placed in a good light, and, if
a child, properly held. In cases where it is possible to get a good view of the
throat, depress the tongue and ^ub the cotton swab gently but freely against
any visible exudate. In other cases, including those in which the exudate is
confined to the larynx, avoiding the tongue, pass the swab far back and rub
it freely against the mucous membrane of the pharynx and tonsils. Without
laying the swab down, withdraw the cotton plug from the culture-tube, insert
the swab, and rub that portion of it which has touched the exudate gently but
thoroughly all over the surface of the blood-serum. Do not push the swab
into the blood-serum, nor break the surface in any way. Then replace the
swab in its own tube, plug both tubes, put them in the box, and return the
culture outfit at once to the station from which it was obtained." The culture-
tubes which have been inoculated are kept in an incubator at 37° C. for twelve
hours and are then ready for examination. Some prefer a method by which
the material from the throat collected on a sterile swab, or, as recommended
206 SPECIFIC INFECTIOUS DISEASES.
by von Esmarcli, on small pieces of sterilized sponge, is sent to the laborator}^
where the cultures and microscopical examination are made b}'^ a bacteriologist.
An immediate diagnosis "without the use of cultures is often possible by
making a smear preparation of the exudate from the throat. The Klebs-Loef-
fler bacilli may be present in sufficient numbers, and may be quite character-
istic to an expert. In this connection may be given the following statement
by Park, who has had such an exceptional experience : " The examination by
a competent bacteriologist of the bacterial growth in a blood-serum tube which
has been properly inoculated and kept for fourteen hours at the body tem-
perature can be thorouglily relied upon in eases where there is visible mem-
brane in the throat, if the culture is made during the period in which the
membrane is forming, and no antiseptic, especially no mercurial solution, has
lately been applied. In cases in which the disease is confined to the larynx or
bronchi, surprisingly accurate results can be obtained from cultures, but in a
certain proportion of cases no diphtheria bacilli will be found in the first
culture, and yet will be abundantly present in later cultures. "We believe,
therefore, that absolute reliance for a diagnosis can not be placed upon a single
culture from the pharynx in purely laryngeal cases.''
Where a bacteriological examination can not he made, the practitioner must
regard as suspicious all forms of throat affections in children, and carry out
measures of isolation and disinfection. In this way alone can serious errors
be avoided. It is not, of course, in the severer forms of membranous angina
that mistake is likely to occur, but in the various lighter forms, many of which
are in reality due to the Klebs-Loeffler bacillus.
A large proportion of the cases of diphtheroid inflammation of the throat
are due to the streptococcus pyogenes. They are usually milder, and the lia-
bility to general infection is less intense; still, in scarlet fever and other spe-
cific fevers some of the most virulent cases of throat disease which we see,
with intense systemic infection, are caused by this micro-organism. These
streptococcus cases are probably much less numerous than the figures wliich
I have given woidd indicate. The more careful examinations in the diphtheria
pavilions of hospitals, particularly in Europe, have shown that in the large
majority of cases admitted the Klebs-Loeffier bacillus is . present. I have
already referred, under the section on scarlet fever, to the question of the
diagnosis between scarlet fever with severe angina and diphtheria.
Prognosis. — In hospital practice the mortality was formerly from 30 to
50 per cent. In the Boston City Hospital the death-rate between 1888 and
189-4 was only once below 40 per cent, and in 1892 and 1893 rose to nearly
50 per cent. Following the introduction of antitoxin from 1895 to 1903 the
death-rate has not once been above 15 per cent, and of late years has been
about 10 or 13 per cent (McCollom). In country places the disease may dis-
play an appalling virulence. In cases of ordinary severity the outlook is usu-
ally good. Death results from involvement of the larjmx, septic infection,
sudden heart-failure, diphtheritic paralysis, occasionally from uraemia, and
sometimes from broncho-pneumonia occurring during convalescence. In
England and "Wales in 1903 there were 6,077 deaths, compared with 9,130, the
average number in the previous decennium (Tatham). Of late years the mor-
tality has been steadily falling. In Boston during the ten years ending 1903
the mortality per 10,000 of the living has ranged from 30.65 to 88.73. The
DIPHTHERIA. 207
mortality has greatly decreased, from 18.03 per 10,000 living in 1894 to 3.51
in 1903 (McCollom).
Prophylaxis. — Isolation of the sick, disinfection of the clothing and of
everything that has come in contact with the patient, careful scrutiny of the
milder cases of throat disorder, and more stringent surveillance in the period
of convalescence are the essential measures to prevent the spread of the dis-
ease. Suspected cases in families or schools should be at once isolated or re-
moved to a hospital for infectious disorders. When a death has occurred from
diphtheria, the body should be wrapped in a sheet which has been soaked in
a corrosive-sublimate solution (1 to 3,000), and placed in a closely sealed
coffin. The funeral should always be private.
In cases of well-marked diphtheria these precautions are usually carried
out, but the chief danger is from the milder cases, particularly the ambulatory
form, in which the disease has perhaps not been suspected. But from such
patients mingling with susceptible children the disease is often conveyed. The
healthy children in a family in which diphtheria exists may carry the disease
to their school-fellows. The question of the influence of isolation hospitals
on the spread of the disease has, I think, been solved in Boston, a city which
has suffered terribly from diphtheria. The ratio of mortality per 10,000 living
in 1893 was 11-|-, and in 1894 it was 19-}-. In 1895 the infectious pavilion
was opened. Prior to that year only about 10 per cent of the reported cases
were treated in hospital ; in succeeding years 50 per cent were treated in hos-
pital. In 1898 the mortality per 10,000 had fallen to 3, and in 1899 it
was 4.9.
A very important matter in the prophylaxis relates to the period of con-
valescence. It has been shown by numerous observations that, after all the
membrane has cleared away, virulent bacilli may persist in the throat from
periods ranging from six weeks to six months, or even longer. There is evi-
dence to show that the disease may be communicated by such patients, so that
isolation should be continued in any given case until"the bacteriological exami-
nation shows that the throat is free.
It can not be too strongly emphasized that the important elements in the
prophylaxis of diphtheria are the rigid scrutiny of the milder types of throat
affection, and the thorough isolation and disinfection of the individual
patients.
Careful attention should be given to the throats and mouths of children,
particularly to the teeth and tonsils, as Caille has urged. Swollen and enlarged
tonsils should be removed. In persons exposed, the antiseptic mouth washes,
such as corrosive sublimate (1 to 10,000), chlorine water (1 to 1,100), or swab-
bing the throat with a diluted Loeffier's solution, should be employed.
Treatment. — The important points are hygienic measures to prevent the
spread of the malady, local treatment of the throat to destroy the bacilli, medi-
cation, general or specific, to counteract the effects of the toxins, and, lastly,
to meet the complications and sequelae.
(a) Hygienic Measures. — The patient should be in a room from which
the carpets, curtains, and superfluous furniture have been removed. The tem-
perature should be about 68°, and thorough ventilation should be secured.
The air may be kept moist by a kettle or a steam-atomizer. If possible, only
the nurse, the child's mother, and the doctor should come in contact with the
208 SPECIFIC INFECTIOUS DISEASES.
patient. During the visit the physician should wear a linen overall, and on
leaving the room he should thoroughly wash his hands and face in a corrosive-
suhlimate solution. The strictest quarantine should be employed against other
members in the house.
(b) Local Treatment. — In mild cases the throat symptoms are alone
prominent. Vigorous local treatment from the outset should be carried out,
taking especial care in all instances to avoid mechanical injury to the tissues.
A very large number of solutions have been recommended. They are best
employed with a swab of cotton-wool or a soft sponge, or irrigation with hot
antiseptic solutions may be used. The direct application with a swab of cot-
ton-wool or sponge is, as a rule, effective. In many young children it is really
a most trying procedure to carry out the treatment, and sometimes one is
compelled to desist. The nurse should hold the child on her knees, well
wrapped in a shawl, with its head resting on her shoulder. The nose is then
held, and so soon as the child opens its mouth a cork should be placed between
the molar teeth. The local application can then be made, or thorough irriga-
tion carried out. In infants the disinfecting fluids are sometimes better
applied through the nostrils. The following solutions may be employed :
Loeffler's solution: Menthol, 10 grammes dissolved in toluol to 36 cc.
Liq. Ferri sesquiclilorati, 4 cc. ; alcohol absol., 60 cc.
Corrosive sublimate, 1 to 1,000, either alone or with tartaric acid, 5
grammes to the litre.
Carbolic acid, 3 per cent in 30 per cent alcohol solution, is much employed;
some prefer to touch the small spots of exudate with pure carbolic acid.
Another solution is: The tincture of the perchloride of iron, a drachm
and a half, in glycerine, one ounce, water, one ounce, with from 15 to 20
minims of carbolic acid. Chlorine water, boric acid, peroxide of hydrogen,
iodoform, lactic acid, trypsin, and papain are also recommended.
LoefBer's solution, which has been given a very thorough trial, is j)erhaps
the most satisfactory.
Nasal diphtheria requires prompt and thorough disinfection of the pas-
sages. Jacobi recommends chloride of sodium, saturated boric acid, or 1
part of bichloride of mercury, 35 of chloride of sodium, and 1,000 of water,
or the 1-per-cent solution of carbolic acid. Loeffler's solution may be diluted
and applied with a syringe or a spray. To be effectual the injection must be
properly given. The nurse should be instructed to pass the nozzle of the
s}Tinge horizontally, not vertically; otherwise the fluid vnll return through
the same nostril.
When the larynx becomes involved, a steam tent may be arranged upon
the bed, so that the child may breathe an atmosphere saturated with moisture.
If the dyspnoea becomes urgent, an emetic of sulphate of zinc or ipecacuanha
may be given. When the signs of obstruction are marked there should be no
delay in the performance of intubation or tracheotomy.
Hot applications to the neck are usually very grateful, particularly to
young children, though in the case of older children and adults the ice poul-
tices are to be j)referred.
(c) General Measures. — The food should be liquid — milk, beef juices,
barley water, albumen water, and soups. The child should be encouraged to
drink water freely. When the phar^mgeal involvement is very great and swal-
DIPHTHERIA. 209
lowing painful, nutritive enemata should be used. In cases with severe con-
stitutional symptoms stimulants should be given early.
Medicines given internally are of very little avail in the disease. There
is still a widespread belief in the profession that forms of mercury are bene-
ficial. The tincture of the perchloride of iron is also very warmly recom-
mended. We are still, however, without drugs which can directly counteract
the toz-albumins of this disease, and we must rely on general measures of feed-
ing and stimulants to support the strength.
The convalescence of the disease is not without its dangers, and patients
should be very carefully watched, particularly if there are signs of heart
weakness.
The diphtheritic paralysis requires rest in bed, and in those cases in which
the heart rhythm is disturbed the avoidance of sudden exertion. In the
chronic forms with wasting, massage, electricity, and strychnine are invaluable
aids. If swallowing becomes very difficult, the patient must be fed with the
stomach-tube, which is very much preferable to feeding per rectum.
(d) Antitoxin Treatment. — As the years go on additional experience
has shown that, thoroughly carried out, this method of treatment is both safe
and efficacious. There are no reasonable grounds for skepticism on the part of
intelligent practitioners, and still less on the part of those in charge of the
hospitals for infectious diseases.
The principle of action depends on the circumstance that the blood-serum
of an animal rendered immune, when introduced into another animal, protects
it from infection with the diphtheria bacilli, and has also an important cura-
tive influence upon diphtheria, whether artificially given to animals, or spon-
taneously acquired by man. In the preparation of the blood-serum a uniform
standard strength is procured. The antitoxin unit is the amount of antitoxin
which, injected into a guinea-pig of 250 grammes in weight, neutralizes 100
times the minimum fatal dose of toxin of standard strength.
Dosage. — This is one of the most important questions relating to the use
of the antitoxin. J. H. McCollom, of the Boston City Hospital, who has prob-
ably had a richer experience with the disease than any man in the United
States, insists that the guiding practice in the use of the antitoxin is to give it
until the characteristic ejffects are produced, whether 4,000 or 70,000 units be
required for this result. He very rightly remarks that in the case of a patient
ill with diphtheria there is no way of estimating the quantity of toxin gener-
ated by the membrane, and therefore one must administer the agent until the
characteristic effect is produced — viz., the shriveling of the membrane, the
diminution of the nasal discharge, the correction of the fetid odor, and a gen-
eral improvement in the condition of the patient. 'No case, he says, in the
acute stage should be considered hopeless. " When one sees a patient with
membrane covering the tonsils and uvula, profuse sanious discharge from the
nose, spots of ecchymosis on the body and extremities, cold, clammy hands
and feet, a feeble pulse, and the nauseous odor of diphtheria, and finds that
after the administration of 10,000 units of antitoxin in two doses the condi-
tion of the patient improves slightly; that after 10,000 units more have been
given there is a marked abatement in the severity of the symptoms ; that when
an additional 10,000 units have been given the patient is apparently out of
danger, and eventually recovers — one must believe in the curative power of
210 SPECIFIC INFECTIOUS DISEASES.
antitoxin, ^^^len one sees a patient in vliom the intubation tube lias been
repeatedly clogged, when the hopeless condition of the patient changes for the
better after the administration of 50.000 units, one can not help but be con-
vinced of the importance of giving large doses of antitoxin in the ver}- severe
and apparently hopeless cases. In the majority of instances these large doses
are not required, particularly if the patients are seen early in the attack, 4,000
to 6,000 units being enough to produce the characteristic efEect on the mem-
brane.*'
Favorable effects are seen in improvement in both the local and general
condition. The swelling of the fauces subsides, the membrane begins to dis-
appear, the temperature falls, and the pulse becomes slower.
Untoward Effects. — Of these the most' common are urticaria and arthral-
gia, but they are trifling and imimportant. Abscess is rare.
Results. — Of 183,256 cases treated in 150 cities previous to the serum
period, the mortality was 38.4 per cent. Since the introduction of serum
132,5-18 cases have been treated, "with a mortality of 14.6 per cent. Leaving
out those not treated with the serum, the mortality was 9.8 per cent (Edwin
Eosenthal). The figures of the Boston City Hospital have already been given
and are of special value, as the number of cases is large, the character severe,
and the Director of the South Department, Dr. McCollom, has had faith in
the treatment and courage in carrying it out.
In Chicago, from 1888 to 1895, the total number of deaths from diph-
theria was 11,488. From 1896 to 1903, the period during the use of anti-
toxin, the deaths were 6,088, a decrease of 47 per cent. Of 586 cases treated
on the first day of the disease there were only 2 deaths ; of 936 cases treated
later than the fourth day there were 216 deaths (A. E. Ee}Tiolds).
Immunization for the Prevention of Diphtheria. — Persons exposed to diph-
theria may be protected by a sufficient dose of the antitoxin. Children, par-
ticularly, should receive an immunizing injection at once. The minimum dose
should be 500 units for a child under two years of age; for older children and
adults larger doses (500 to 1,000) are employed, which may be repeated in a
few days if necessary. In New York (city) since January, 1895, 13,000 per-
sons have been so treated^ of whom only 40 contracted the disease and only
one died.
XVII. ERYSIPELAS.
Definition. — An acute, contagious disease, characterized by a special in-
flammation of the skin caused by streptococcus erysipelatos seu p3"ogenes.
Etiology. — Erysipelas is a widespread affection, endemic in most com-
munities, and at certain seasons epidemic. TVe are as yet ignorant of the
atmospheric or telluric influences which favor the diffusion of the poison.
It is particularly prevalent in the spring of the vear. Of 2,012 cases col-
lected by Anders, 1,214 occurred during the first five months of the year.
April had the largest number of cases. The affection prevails extensiveh'' in
old. ill-ventilated hospitals and institutions in which the sanitary conditions
are defective. With tlie improved sanitation of late years the number of cases
has materially diminished. It has been observed, however, to break out in new
institutions under the most favorable hygienic circumstances. Erysipelas is
ERYSIPELAS. 211
both contagious and inoculable; but, except under special conditions, the poi-
son is not very virulent and does not seem to act at any great distance. It
can be conveyed by a third person. The poison certainly attaches itself to the
furniture, bedding, and walls of rooms in which patients have been confined.
The disposition to the disease is widespread, but the susceptibility is
specially marked in the case of individuals with wounds or abrasions of any
sort. Eecently delivered women and persons who have been the subjects of
surgical operations are particularly prone to it. A wound, however, is not
necessary, and in the so-called idiopathic form, although it may be difficult to
say that there was not a slight abrasion about the nose or lips, in very many
cases there certainly is no observable external lesion.
Chronic alcoholism, debility, and Bright's disease are predisposing agents.
Certain persons show a special susceptibility to erysipelas, and it may recur
in them repeatedly. There are instances, too, of a family predisposition.
The specific agent of the disease is a streptococcus growing in long chains,
which is included under the group name Streptococcus pyogenes, with which
Streptococcus erysipelatos appears to be identical. The fever and constitu-
tional symptoms are due in great part to the toxins ; the more serious visceral
complications are the result of secondary metastatic infection.
Immunity. — Susceptible animals can be rendered immune to virulent
streptococci by repeated non-lethal injections of cultures. Marmorek's pro-
tective serum, prepared by inoculating the horse and other animals with cul-
tures of intensified virulence, belongs to the bactericidal and not to the anti-
toxic sera. Notwithstanding some apparently favorable results, its value in
the treatment of human infections has not been demonstrated.
Morbid Anatomy .-^Erysipelas is a simple inflammation. In its uncom-
plicated forms there is seen, post mortem, little else than inflammatory oedema.
Investigations have shown that the cocci are found chiefly in the l}Tnph-spaces
and most abundantly in the zone of spreading inflammation. In the unin-
volved tissue beyond the inflamed margin they are to be found in the lymph-
vessels, and it is here, according to Metschnikoff and others, that an active
warfare goes on between the leucocytes and the cocci (phagocytosis). In more
extensive and virulent forms of the disease there is usuall}^ suppuration.
Infarcts occur in the lungs, spleen, and kidneys, and there may be the gen-
eral evidences of pysemic infection. Some of the worst cases of malignant
endocarditis are secondary to erysipelas ; thus, of 23 cases, 3 occurred in con-
nection with this disease. Septic pericarditis and pleuritis also occur. As
just mentioned, the disease may in rare cases extend to and involve the
meninges. Pneumonia is not a very common complication. Acute nephritis
is also met with ; it is often ingrafted upon an old chronic trouble.
Symptoms. — Tlie following description applies specially to erysipelas of the
face and head, the form of the disease which the physician is most commonly
called upon to treat.
The incuhation is variable, probably from three to seven days.
The stage of invasion is often marked by a rigor, and followed by a rapid
rise in the temperature and other characteristics of an acute fever. When
there is a local abrasion, the spot is slightly reddened; but if the disease is
idiopathic, there is seen within a few hours slight redness over the bridge of
the nose and on the cheeks. The swelling; and tension of the skin increase and
212 SPECIFIC INFECTIOUS DISEASES.
■within twenty-four hours the external symptoms are well marked. The skin
is smooth, tense, and oedematous. It looks red, feels hot, and the superficial
layers of the epidermis may be lifted as small blebs. The patient complains of
an unpleasant feeling of tension in the skin; the swelling rapidly increases;
and during the second day the eyes are usually closed. The first-affected parts
gradually become pale and less swollen as the disease extends at the periphery.
When it reaches the forehead it progresses as an advancing ridge, perfectly well
defined and raised; and often, on palpation, hardened extensions can be felt
beneath the skin which is not 3^et reddened. Even in a case of moderate sever-
ity, the face is enormously swollen, the eyes are closed, the lips greatly oedema-
tous, the ears thickened, the scalp is swollen, and the patient's features are
quite unrecognizable. The formation of blebs is common on the eyelids, ears,
and forehead. The cervical lymph-glands are swollen, but are usually masked
in the oedema of the neck. The temperature keeps high without marked remis-
sions for four or five days and then defervescence takes place by crisis. Leu-
cocytosis is present. Kirkbride has noted the presence in one case of leucin
and t}Tosin in the urine. The general condition of the patient varies much
with his previous state of health. In old and debilitated persons, particularly
in those addicted to alcohol, the constitutional depression from the outset may
be very great. Delirium is present, the tongue becomes dry, the pulse feeble,
and there is marked tendency to death from toxemia. In the majority of
cases, however, even with extensive lesions, the constitutional disturbance, con-
sidering the height of the fever range, is slight. The mucous membrane of the
mouth and throat may be swollen and reddened. The erysipelatous inflamma-
tion may extend to the lar}Tix, but the severe oedema of this part occasionally
met with is commonly due to the extension of the inflammation from without
inward.
There are cases in which the inflammation extends from the face to the
neck, and over the chest, and may gradually migrate or wander over the greater
part of the body (E. migrans).
The close relation between the erysipelas coccus and the pus organisms is
shown by the frequency vdth which suppuration occurs in facial erysipelas.
Small cutaneous abscesses are common about the cheeks and forehead and
neck, and beneath the scalp large collections of pus may accumulate. Sup-
puration seems to occur more frequently in some epidemics than in others, and
at the Philadelphia Hospital one year nearly all the cases in the erysipelas
wards presented local abscesses.
Complications. — Meningitis is rare. The cases in which death occurs with
marked brain symptoms do not usually show, post mortem, meningeal
affection.
Pneumonia is an occasional complication. Ulcerative endocarditis and
septicsemia are more common. Albuminuria is almost constant, particularly
in persons over fiftv. True nephritis is occasionally seen. Da Costa has
called attention to curious irregular returns of the fever which occur during
convalescence without any aggravation of the local condition.
The diagnosis rarely presents any difficulty. The mode of onset, the rapid
rise in fever, and the characters of the local disease are quite distinctive.
Prognosis. — Healthy adults rarely die. The general mortality in hospitals
is about 7 per cent, in private practice about 4 per cent (Anders). In the
SEPTICAEMIA AND PYEMIA. 213
new-born, when the disease attacks the navel, it is almost always fatal. In
drunkards and in the aged erysipelas is a serious affection, and death may
result either from the intensity of the fever or, more commonly, from toxaemia.
The wandering or ambulatory erysipelas, which has a more protracted course,
may cause death from exhaustion.
Treatment. — Isolation should be strictly carried out, particularly in hos-
pitals. A practitioner in attendance upon a case of erysipelas should not
attend cases of confinement.
The disease is self-limited and a large majority of the cases get well with-
out any internal medication. I can speak definitely on this point, having, at
the Philadelphia Hospital, treated many cases in this way. The diet should
be nutritious and light. Stimulants are not required except in the old and
feeble. For the restlessness, delirium, and insomnia, chloral or the bromides
may be given; or, if these fail, opium. When the fever is high the patient
may be bathed or sponged, or, in private practice, if there is an objection to
this, antipyrin or antifebrin may be given.
Of internal remedies believed to influence the disease, the tincture of the
perchloride of iron has been highly recommended. At the Montreal General
Hospital this was the routine treatment, and doses of half a drachm to a
drachm were given eyevj three or four hours. I am by no means convinced
that it has any special action ; nor, so far as I know, has any medicine, given
internally, a definite control over the course of the disease.
Of local treatment, the injection of antiseptic solutions at the margin of
the spreading areas has been much practised. Two-per-cent solutions of car-
bolic acid, the corrosive sublimate and the biniodide of mercury have been
much used. The injection should be made not into but just a little beyond
the border of the inflamed patch. F. P. Henry has treated a large number
of cases at the Philadelphia Hospital with the last-mentioned drug, and this
mode of practice is certainly most rational.
Of local applications, ichthyol is at present much used. The inflamed
region may be covered with salicylate of starch. Perhaps as good an appli-
cation as any is cold water, which was highly recommended by Hippocrates,
XVIII. SEPTIC-ffiMIA AND PY-ffiMIA.
Certain terms must first be defined.
An infection is the morbid process induced by the invasion and growth in
the body of pathogenic micro-organisms. An infection may be local, as in
a boil, or general, as in some cases of anthrax.
An intoxication is the morbid condition caused by the absorption of toxins,
in large part derived from pathogenic organisms. The term saprcemia is the
equivalent of septic intoxication.
A hard-and-fast line can not be drawn between an infection and an intoxi-
cation, but agents of infection alone are capable of reproduction, whereas those
of intoxication are chemical poisons, some of which are produced by the agency
of bacteria, or by vegetable and animal cells. Infectious diseases which are
communicated directly from one person to another are termed contagious, and
the infecting agent is sometimes spoken of as a contagium. " Whether or not
214 SPECIFIC INFECTIOUS DISEASES.
an infectious disease is contagious in the ordinary sense depends upon the
nature of the infectious agent, and especially upon the manner of its elimina-
tion from and reception by the body. Most but not all contagious diseases are
infectious. Scabies is a contagious disease, but it is not infectious " (Welch),
There are three chief clinical types of infection.
1. Local Iis^pections with the Development of Toxins.
This is the common mode of invasion of many of the diseases which we
have already considered. Tetanus, diphtheria, erysipelas, and pneumonia are
diseases which have sites of local infection in which the pathogenic organisms
develop ; but the constitutional efEects are caused by the absorption of the poi-
sonous products. The diphtheria toxin produces all the general symptoms, the
tetanus toxin every feature, of the disease without the presence of their re-
spective bacilli. Certain of the symptoms following the absorption of the tox-
ins are general to all ; others are special and peculiar, according to the organ-
ism which produces them. A chill, fever, general malaise, prostration, rapid
pulse, restlessness, and headache are the most frequent. With but few excep-
tions the febrile disturbance is the most common feature. The most serious
effects are seen upon the nervous system and upon the heart, and the gravity
of the symptoms on the part of these organs is to some extent a measure of the
intensity of the intoxication. The organisms of certain local infections pro-
duce poisons which have special actions; thus the diphtheria toxin, besides
having the effects already referred to, is especially prone to attack the nervous
system and to cause peripheral neuritis. The tetanus toxin has a specific
action on the motor neurones.
2. Septicemia.
Formerly, and in a surgical sense, the term '' septicaemia " was used to
designate the invasion of the blood and tissues of the body by the organisms
of suppuration, but in the medical sense the term may be applied to any con-
dition in which, with or without a local site of infection, there is microbic
invasion of the blood and tissues, but without metastatic foci of suppuration.
Owing to the great development of bacteria in the blood, and in order to sepa-
rate it sharply from local infectious processes with toxic invasion of the body,
it is proposed to call this condition bactersemia; toxaemia denotes the latter
state.
(a) Progeessive Septicemia eeom Local Infection. — The common
streptococcus and staphylococcus infection is as a rule first local, and the tox-
ins alone pass into the blood. In other instances the cocci appear in the blood
and throughout the tissues, causing a septicaemia which intensifies greatly the
severity of the case. Other infections in which the bacterial invasion, local at
first, may become general are pneumonia, typhoid fever, anthrax, gonorrhoea,
and puerperal fever.
The clinical features of this form are well seen in the cases of puerperal
septicaemia or in dissection wounds, in which the course of the infection may
be traced along the lymphatics. The svmptoms usually set in within twenty-
four hours, and rarely later than the third or fourth day. There is a chill
or chilliness^ with moderate fever at firstj which gradually rises and is marked
SEPTICEMIA AND PYAEMIA. 215
by daily remissions and even intermissions. The pulse is small and com-
pressible, and may reach 120 or higher. Gastro-intestinal disturbances are
common, the tongue is red at the margin, and the dorsum is dry and dark.
There may be early delirium or marked mental prostration and apathy. As
the disease progresses there may be pallor of the face or a yellowish tint.
Capillary haemorrhages are not uncommon.
In streptococcus cases we are beginning to recognize the fact that these
infections are not always so serious as we thought. Death may occur within
twenty-four hours or be delayed for several days, even for weeks, and recovery
may occur. One case recently showed streptococci in the blood for six weeks,
but ultimately recovered (Cole). On post-mortem examination there may be
no gross focal lesions in the viscera, and the seat of infection may present only
slight changes. The spleen is enlarged and soft, the blood may be extremely
dark in color, and haemorrhages are common, particularly on the serous sur-
faces. Neither thrombi nor emboli are found. Certain clinical features sepa-
rate the streptococcus frohi the staphylococcus infection, chiefly in the absence
of delirium, a rather abnormal mental acuteness, and in the presence of a
greater degree of anaemia.
Many instances of septicaemia are combined infections ; thus in diphtheria
streptococcus septicaemia is a common, and the most serious, event. The local
disease and the symptoms produced by absorption of the toxins dominate the
clinical picture ; but the features are usually much aggravated by the systemic
invasion. A similar infection may occur in typhoid fever and in tuberculosis,
and may obscure the typical picture. These secondary septicaemias are caused
most fre(|uently by the streptococcus, but may result from the invasion of
other bacteria.
(&) General Septicemia without Eecognizable Local Infection. — -
Crypto genetic Septiccemias. — This is a group of very great interest to the
physician, the full importance of which we are only now beginning to recog-
nize.
The subjects when attacked may be in perfect health ; more commonly they
are already weakened by acute or chronic illness. The pathogenic organisms
are varied. Streptococcus pyogenes is the most common; the forms of
staphylococcus more rare. Other occasional causal agents are Micrococcus
lanceolatus (pneumococcus). Bacillus proteus, and Bacillus pyocyaneus. Be-
tween May 1, 1892, and June 1, 1895, there were examined in the post-mortem
room from my wards 21 cases of general infection, of which 13 were due to
Streptococcus pyogenes, 2 to Staphylococcus pyogenes, and 6 to the pneumo-
coccus. In 19 of these cases the patients were already the subjects of some
other malady, which was aggravated, or in most instances terminated, by the
general septicemia. The symptoms vary somewhat with the character of the
micro-organisms. In the streptococcus cases there may be chills with high,
irregular fever, and a more characteristic septic state than in the pneumo-
coccus infection.
Most of these cases come correctly under the term " cryptogenetic septi-
caemia" as employed by Leube, inasmuch as the local focus of infection is
not evident during life, and may not be found after death. Although most
of these cases are terminal infections, yet it is well to bear in mind that there
are instances of this type of affection coming on in apparently healthy persons.
216 SPECIFIC INFECTIOUS DISEASES.
The fever may be extremely irregular, characteristically septic, and persist
for many weeks. Foci of suppuration may not develop, and may not be found
even at autopsy. I have on several occasions met with cases of an intermit-
tent pyrexia persisting for weeks, in which it seemed impossible to give any
explanation of the phenomena, and some which ultimately recovered, and in
which tuberculosis and malaria could be almost positively excluded. These
cases require to be carefully studied bacteriologically. Dreschfeld has de-
scribed them as idiopathic intermittent fever of pysemic character. Local
symptoms may be absent, though in three of his cases there was enlargement
of the liver, and in two the condition was a diffuse suppurative hepatitis. The
pyocyanic disease, or cyano-pyfemia, is an extremely interesting form of infec-
tion with Bacillus pyocyaneus, of which a larger number of cases have been
reported of late years. (See Wollstein's paper. Archives of Pediatrics, Octo-
ber, 1897, and Barker, Jour. Am. Med. Assoc, 1897.)
3. Septico-py^mia,
The pathogenic micro-organisms which invade the blood and tissues may
settle in certain foci and there cause suppuration. When multiple abscesses
are thus produced in connection with a general infection, the condition is
known as pyramia or, perhaps better, septico-pyaemia. There are no specific
organisms of suppuration, and the condition of pysemia may be produced by
organisms other than the streptococci and staphylococci, though these are the
most common. Other forms which may invade the system and cause foci of
suppuration are Micrococcus lanceolatus, the gonococcus. Bacillus coli, Bacillus
typhosus, Bacillus prateus, Bacillus pyocyaneus, Bacillus influenzce, and very
probably the anaerobic bacteria of Veillon and Zuber. In a large proportion of
all cases of pyaemia there is a focus of infection, either a suppurating exter-
nal wound, an osteomyelitis, a gonorrhoea, an otitis media, an empyema, or an
area of suppuration in a lymph-gland or about the appendix. In a large
majority of all these cases the common pus cocci are present.
In a suppurating wound, for example, the pus organisms induce hyaline
necrosis in the smaller vessels with the production of thrombi and purulent
phlebitis. The entrance of pus organisms in small numbers into the blood
does not necessarily produce pyaemia. Commonly the transmission to various
parts from the local focus takes place by the fragments of thrombi which pass
as emboli to different parts, where, if the conditions are favorable, the pus
organisms excite suppuration. A thrombus which is not septic or contami-
nated, when dislodged and impacted in a distant vessel, produces at most only
a simple infarction; but, coming from an infected source and containing pus
microbes, an independent centre of infection is established wherever the em-
bolus may lodge. These independent suppurative centres in pyaemia, known as
embolic or metastatic abscesses, have the following distribution:
(a) In external wounds, in osteo-myelitis, and in acute phlegmon of the
skin, the embolic particles very frequently excite suppuration in the lungs,
producing the well-known wedge-shaped pyaemic infarcts ; from these, or rarely
by paradoxical embolism, or direct passage of bacteria or minute emboli
through the pulmonary capillaries, metastatic foci of inflammation may occur
in other parts.
(6) Suppurative foci in the territory of the portal system, particularly in
SEPTICEMIA AND PYJEMIA. 217
the intestines, produce metastatic abscesses in the liver with or without sup-
purative pylephlebitis.
Endocarditis is an event which is very liable to occur in all forms of sep-
ticasmia, and modifies materially the character of the clinical features. Strep-
tococci and staphylococci are the most common organisms present in the vege-
tations, but the pneumococci, gonococci, tubercle bacilli, typhoid bacilli,
anthrax bacilli, and other forms have been isolated. The vegetations which
grow at the site of the valve lesion become covered with thrombi, particles
of which may be dislodged and carried as emboli to different parts of the body,
causing multiple abscesses or infarcts.
Symptoms of Septico-pysemia. — In a case of wound infection, prior to the
onset of the characteristic symptoms, there may be signs of local trouble, and
in the case of a discharging wound the pus may change in character. The
onset of the disease is marked by a severe rigor, during which the temperature
rises to 103° or 104° and is followed by a profuse sweat. These chills are
repeated at intervals, either daily, or every other day. In the intervals there
may be slight pyrexia. The constitutional disturbance is marked and there
are loss of appetite, nausea, and vomiting, and, as the disease progresses, rapid
emaciation. Transient erythema is not uncommon. Local symptoms usually
occur. If the lungs become involved there are dyspnoea and cough. The
physical signs may be slight. Involvement of the pleura and pericardium is
common. The anasmia, often profound, causes great pallor of the skin, which
later may be bile-tinged. The spleen is enlarged, and there may be intense
pain in the side, pointing to perisplenitis from embolism. Usually in the
rapid cases a typhoid state supervenes, and the patient dies comatose.
In the chronic cases the disease may be prolonged for months; the chills
recur at long intervals, the temperature is irregular, and the condition of the
patient varies from month to month. The course is usually slow and progress-
ively downward.
Diagnosis. — Pyaemia is a disease frequently overlooked and often mistaken
for other affections.
Cases following a wound, an operation, or parturition are readily recog-
nized. On the other hand, the following conditions may be overlooked:
Osteo-myelitis. — Here the lesion may be limited, the constitutional symp-
toms severe, and the course of the disease very rapid. The cause of the trouble
may be discovered only post mortem.
So, too, acute septico-pysemia may follow gonorrhoea or a prostatic abscess.
Cases are sometimes confounded with typhoid fever, particularly the more
chronic instances, in which there are diarrhoea, great prostration, delirium,
and irregular fever. The spleen, too, is often enlarged. The marked leuco-
cytosis is an important differential point.
In some of the instances of ulcerative endocarditis the diagnosis is very
difficult, particularly in what is known as the typhoid, in contradistinction
to the septic, type of this disease. In acute miliary tuberculosis the symp-
toms occasionally resemble those of septicaemia, more commonly those of
typhoid fever.
The post-fehrile artliritides, such as occur after scarlet fever and gonor-
rhoea, are really instances of mild septic infection. The joints may some-
times suppurate and pyemia develop. So, also, in tuberculosis of the kidneys
218 SPECIFIC INFECTIOUS DISEASES.
and calculous pyelitis recurring rigors and sweats due to septic infection are
common. In some latitudes septic and pysemic processes are too often con-
founded with malaria. In early tuberculosis, or even when signs of excava-
tion are present in the lungs, and in cases of suppuration in various parts,
particularly empyema and abscess of the liver, the diagnosis of malaria is
made. The practitioner may take it as a safe rule, to which he will find very
few eseeptions, that an intermittent fever which resists quinine is not malaria.
Other conditions associated with chills which may be mistaken for pygemia
are profound ana?mia, certain cases of Hodgkin's disease, the hepatic inter-
mittent fever associated with the lodgment of gall-stones at the orifice of the
common duct, rare cases of essential fever in nervous women, and the inter-
mittent fever sometimes seen in rapidly growing cancer.
Treatment. — (a) Surgical. — In pyaemia, where the pus is accessible, free
evacuation and drainage is often the only treatment required. In a case of
empygema with weeks of high and irregular fever the day after operation the
temperature is normal, and may remain so. In some cases with a local infec-
tion Bier's method of Iwpersmia has been used with success, but where the
focus of manufacture of the poison is accessible the knife should be used.
Unfortunately, in only too many cases the focus of infection is not accessible;
it then is a septicsemia, and for such cases the bacteriologists have intro-
duced the treatment with vaccines.
(h) Vaccine Treatment. — By blood cultures or by cultures from the focus
of infection the organism is isolated, then a vaccine is prepared, and, if
Wright's method is followed, the use and dose are regulated by the opsonic
index of the patient. In many cases where the germ can not be isolated and
the condition is one of septic fever the ordinary antistreptococcus serum is
used, or one of the polyvalent sera. Good results are obtained in a few cases,
and we are working in the right direction, but the method is as yet only in the
experimental stage.
(c) Drugs. — There are none which control septic fever. The coal-tar
products are of doubtful service. Quinine may be used. Cold bathing is
much the best measure to control the fever.
4. Terminal Infections.
There is truth in the paradoxical statement that persons rarely die of the
disease with which they sufi'er. Secondary, terminal, infections carry ofE many
of the incurable cases. Flexner analyzed 255 cases of chronic renal and cardiac
disease in which complete bacteriological examinations were made at. autopsy.
Excluding tuberculous infection, 213 gave positive and 42 negative results.
The infections may be local or general. The former are extremely common,
and are found in a large proportion of all cases of Bright's disease, arterio-
sclerosis, heart disease, cirrhosis of the liver, and other chronic disorders.
Affections of the serous membranes (acute pleurisy, pericarditis, or perito-
nitis), meningitis, and endocarditis are the most frequent lesions. It is per-
haps safe to say that the majority of cases of advanced arterio-sclerosis and
of Bright's disease succumb to these intercurrent infections. The infective
agents are very varied. The streptococcus is the most common, but the pneu-
mococcus, staphylococcus and gonococcus, and the proteus, pyocyaneus, and
RHEUMATIC FEVER- 219
gas bacilli are also met with. It is surprising in how many instances of
arterio-sclerosis, of chronic heart disease, of Bright's disease, and particularly
of cirrhosis of the liver in Flexner's series the fatal event was determined by
an acute tuberculosis of the peritonseum or pleura.
The general terminal infections are somewhat less common. Of 85 eases
of chronic renal disease in which Flexner found micro-organisms at autopsy,
38 exhibited general infections; of 48 cases of chronic cardiac disease, in 14
the distribution of bacteria was general. The blood-serum of persons suffer-
ing from advanced chronic disease was found by him to be less destructive to
the staphylococcus aureus than normal human serum. Other diseases in which
general terminal infection may occur are Hodgkin's disease, leukaemia, and
chronic tuberculosis.
And, lastly, probably of the same nature is the terminal entero-colitis so
frequently met with in chronic disorders.
XIX. RHEUMATIC FEVER.
Definition. — An acute, non-contagious fever, dependent upon an unknown
infective agent, and characterized by multiple arthritis and a marked tendency
to inflammation of the fibrous tissues.
Etiology. — Distribution and Prevalence. — It prevails in temperate
and humid climates. Church has collected interesting statistics on this point.
Oddly enough, the two countries with the highest admission in the British
army per thousand of strength — Egypt, 7.03, and Canada, 6.26 — ^have climates
the most diverse. In 1903 in England and Wales 1,812 deaths were due to
rheumatic fever (Tatham). The disease prevails more in the northern lati-
tudes. In the Montreal General Hospital there were for the twelve years
ending 1903, 2 deaths in 482 cases among 12,044 admissions; at the Eoyal
Victoria Hospital, Montreal, for ten years ending 1903, 3 deaths in 285 cases
among 9,286 admissions (John McCrae). At the Johns Hopkins Hospital
for the fifteen years ending 1904, there were 360 admissions (330 patients)
and 9 deaths (T. McCrae). The general impression is that the disease pre-
vails more in the British Isles than elsewhere; but, as Church remarks, the
returns are very imperfect (this holds good everywhere). In Norway, where
cases of rheumatic fever are notified, there were for the four years 1888-92
13,654 cases, with 250 deaths.
Season. — In London the cases reach the maximum in the months of Sep-
tember and October. In the Montreal General Hospital Bell's statistics of
456 cases show that the largest number was admitted in February, March,
and April. And the same is true in Baltimore, 55 per cent of our cases were
admitted in the first four months of the year (McCrae). The disease prevails
most in the dry years or a succession of such, and is specially prevalent when
the subsoil water is abnormally low and the temperature of the earth high
(Newsholme).
Age. — Young adults are most frequently affected, but the disease is by no
means uncommon in children between the ages of ten and fifteen years. Suck-
lings are rarely attacked. Milton Miller has analyzed 19 undoubted cases.
The eases have to be distinguished from a totally different affection, the pyo-
220 SPECIFIC INFECTIOUS DISEASES.
genie arthritis of infants. Of 456 cases admitted to the Montreal General
Hospital there were, under fifteen years, 4.38 per cent; from fifteen to twent}'--
five years, 48.68 per cent; from twenty-five to thirty- five years, 25.87 per cent;
from thirty-five to forty- five years, 13.6 per cent; above forty-five years, 7.4
per cent. Of our 360 admissions, 110 were in the third decade and 65 per
cent below the thirtieth year of age (McCrae). Ten per cent of the cases
had the first attack in the first decade. Of the 655 cases analj^zed by Whip-
ham for the Collective Investigation Committee of the British Medical Asso-
ciation, only 32 cases occurred under the tenth 3^ear and 80 per cent between
the twentieth and fortieth years. These figures do not give the ratio of cases
in children, in whom the milder types of arthritis are very common.
Sex. — If all ages are taken, males are affected oftener than females. Of
our patients, 239 were males, 91 females. In the Collective Investigation Ee-
port there were 375 males and 279 females. Up to the age of twenty, how-
ever, females predominate. Between the ages of ten and fifteen girls are more
prone to the disease.
Heredity. — It is a deeply groimded belief with the public and the pro-
fession that rheumatism is a family disease, but Church thinks the evidence
is still imperfect. In 25 per cent of our cases there was a history of the dis-
ease in the family. The not rare occurrence in several members of the same
family is used by those who believe in the infectious origin as an argument
in favor of its being a house disease.
Occupations which necessitate exposure to cold and great changes of tem-
perature predispose strongly, and the disease is met with oftenest in drivers,
servants, bakers, sailors, and laborers.
Chill. — Exposure to cold, a wetting, or a sudden change of temperature
are among the factors in determining the onset of an attack, but they were
present in only 12 per cent of our cases.
Xot only does an attack not confer immunity, but as in pneumonia pre-
disposes the subject to the disease.
Rheumatic Fever as an Acute Infectious Disease. — (a) General Evi-
dence.— Eheumatic fever, as Xewsholme has shown, occurs in epidemics with-
out regular periodicity, recurring at intervals of three, four, or six years, and
varying much in intensity. A severe epidemic is apt to be followed by two
or three mild outbreaks. " The curves of the mortality statistics , . . approx-
imate very closely to those of pyemia, puerperal fever, and erysipelas, dis-
eases which are certainly associated with specific micro-organisms" (Church).
The constancy also of the seasonal variations is an additional support to
this view.
(6) Clinical Features. — Physicians have long been impressed with the
striking similarity of the s}Tnptoms to those of septic infection. In the char-
acter of the fever, the mode of involvement of the joints, the tendency to re-
lapse, the sweats, the anaemia, the leucocytosis, and, above all, the great liabil-
ity to endocarditis and involvement of the serous membranes, the disease
resembles pyaemia very closely, and may, indeed, be taken as the very type of an
acute infection. But, as Stephen Mackenzie remarks, acute rheumatism should
be considered not simply from the point of view of the rheumatic polyarthritis
of the adult, but as a whole in its manifestations at difEerent periods of life;
yet even from this standpoint the multiform manifestations of the rheumatic
RHEUMATIC FEVER. 221
j^oison in childhood and young adults may very reasonably be referred to the
effect of the toxins of micro-organisms.
(c) Special Evidence. — The bacteriology of the disease is still under dis-
cussion. Many organisms have been described, a special bacillus by Achalme,
forms of streptococci, and a diplococcus by Wasserman, which is probably the
same as that described in England by Poynton and Payne, Ainley Walker,
Shaw and Beattie. This latter, which has been called the Micrococcus rlieu-
maticus, has been isolated from the throat, joints, and exudates in persons
suffering with rheumatic fever. Poynton, Payne, and others have produced
with this organism, injected into rabbits, endocarditis, arthritis, and subcu-
taneous nodules. In a series of cases in my clinic Cole could not confirm these
results, studying blood cultures and the effusion into the joints. On the other
hand, he was able with strains of streptococci from various sources to produce
experimentally endocarditis and arthritis. A view very commonly held is that
the organism producing the disease is an attenuated streptococcus. Beattie,
in a recent paper, claims that the results obtained by injecting streptococci are
different from those produced by Micrococcus rheumaticus. A point of great
interest is that Ainley Walker has obtained formic acid from the cultures of
this germ. The problem is one of great difficulty and of the first importance,
in view of the suffering and incapacity caused by rheumatic fever.
There is considerable evidence against the view that it is simply a mild
pyogenic infection. Salicylates have no effect on the ordinary streptococcus
infections, and the clinical course in the streptococcus arthritis is very differ-
ent; moreover, rheumatic joints never suppurate. The isolation of strepto-
cocci may simply indicate the presence of secondary streptococcus invaders
such as occur in scarlet fever and small-pox.
Other views as to the nature of rheumatism are the metabolic or chemical:
that it depends upon a morbid material produced within the system in de-
fective processes of assimilation. It has been suggested that this material is
lactic acid (Prout) or certain combinations with lactic acid (Latham).
A nervous theory of acute rheumatism was advocated by the late J. K.
Mitchell, of Philadelphia, who believed that the nerve centres were primarily
affected by cold and that the local lesions were really trophic in character.
Morbid Anatomy. — There are no changes characteristic of the disease.
The affected joints show hyperemia and swelling of the synovial membranes
and of the ligamentous tissues. There may be slight erosion of the cartilage.
The fluid in the joint is turbid, albuminous in character, and contains leuco-
cytes and a few fibrin flakes. Pus is very rare in uncomplicated cases. Eheu-
matic fever rarely proves fatal, except when there are serious complications,
such as pericarditis, endocarditis, myocarditis, pleurisy, or pneumonia. The
conditions found show nothing peculiar, nothing to distinguish them from
other forms of inflammation. In death from hyperpyrexia no special changes
are found. The blood usually contains an excessive amount of fibrin. In the
secondary rheumatic inflammations, as pleurisy and pericarditis, various pus
organisms have been found, possibly the result of a mixed infection.
Symptoms. — As a rule, the disease sets in abruptly, but it may be preceded
by irregular pains in the joints, slight malaise, sore throat, and particularly by
tonsillitis. A definite rigor is uncommon; more often there is slight chilli-
ness. The fever rises quickly, and with it one or more of the joints become
222 SPECIFIC INFECTIOUS DISEASES.
painful. Within twenty-four hours from the onset, the disease is fully mani-
fest. The temperature range is from 102° to 104°. The pulse is frequent, soft,
and usually above 100. The tongue is moist, and rapidly becomes covered with
a white fur. There are the ordinary symptoms associated with an acute fever,
such as loss of appetite, thirst, constipation, and a scanty, highly acid, highly
colored urine. In a majority of the cases there are profuse, very acid sweats,
of a peculiar sour odor. Sudaminal and miliary vesicles are abundant, the
latter usually surrounded by a minute ring of hypersemia. The mind is clear,
except in the cases with hyperpyrexia. The affected joints are painful to move,
soon become swollen and hot, and present a reddish flush. The order of fre-
quency of involvement of the joints in our series was knee, ankle, shoulder,
wrist, elbow, hip, hand, foot. The joints are not attacked together, but suc-
cessively. For example, if the knee is first affected, the redness may disappear
from it as the wrists become painful and hot. The disease is seldom limited to
a single articulation. The amount of swelling is variable. Extensive effusion
into a joint is rare, and much of the enlargement is due to the infiltration of
the periarticular tissues with serum. The swelling may be limited to the joint
proper, but in the wrists and ankles it sometimes involves the sheaths of the
tendons and produces great enlargement of the hands and feet. Correspond-
ing joints are often affected. In attacks of great severity every one of the
larger joints may be involved. The vertebral, sterno-clavicular, and phalan-
geal articulations are less often inflamed in acute than in gonorrhoeal rheuma-
tism. Perhaps no disease is more painful than acute polyarthritis. The ina-
bility to change the posture without agonizing pain, the drenching sweats, the
prostration and utter helplessness, combine to make it one of the most distress-
ing of febrile affections. A special feature of the disease is the tendency of
the inflammation to subside in one joint while increasing with great intensity
in another.
The temperature range in an ordinary attack is between 102° and 104°.
In only 18 of our cases did the temperature rise above 104°. In 100 it reached
103° or over. It is peculiarly irregular, with marked remissions and exacerba-
tions, depending very much upon the intensity and extent of the articular in-
flammation. Defervescence is usually gradual. The profuse sweats materially
influence the temperature curve. If a two-hourly chart is made and observa-
tions upon the sweats are noted, the remissions will usually be found coinci-
dent with the sweats. The perspiration is sour-smelling and acid at first; but,
when persistent, becomes neutral or even alkaline.
The blood is profoundly altered in acute rheumatism. There is, indeed,
no acute febrile disease in which an auEemia occurs with greater rapidity.
The average leucocyte count in our cases was about 12,000 per c.mm.
With the high fever a murmur may often be heard at the apex region.
Endocarditis is also a common cause of an apex 'bruit. The heart should be
carefully examined at the first visit and subsequently each day.
The urine is, as a rule, reduced in amount, of high density and high color.
It is very acid, and, on cooling, deposits urates. The chlorides may be greatly
diminished or even absent. Formic acid is present (Walker). Febrile albu-
minuria is not uncommon.
The saliva may become acid in reaction and is said to contain an excess
of sulphocyanides.
RHEUMATIC FEVER. 223
Subacute Rheumatism. — This represents a milder form of the disease, in
which all the symptoms are less pronounced. The fever rarely rises above
101°; fewer joints are involved; and the arthritis is less intense. The cases
may drag on for weeks or months, and the disease may finally become chronic.
It should not be forgotten that in children this mild or subacute form may be
associated with endocarditis or pericarditis.
Complications. — These are important and serious.
(1) Hypekpyeexia. — The temperature may rise rapidly a few days after
the onset, and be associated with delirium; but not necessarily, for the tem-
perature may rise to 108° or, as in one of Da Costa's cases, 110°, without cere-
bral symptoms. Hyperpyrexia is most common in first attacks, 57 of 107 eases
(Church). It is most apt to occur during the second week. Delirium may
precede or follow its onset. As a rule, with the high fever, the pulse is feeble
and frequent, the prostration is extreme, and finally stupor supervenes. In
our series there was no instance of hyperpyrexia, which seems rare in the
United States.
(3) Cardiac Affection's. — (a) Endocarditis, the most frequent and seri-
ous complication, occurs in a considerable percentage of all cases. Of 889
cases, 494 had signs of old or recent endocarditis (Church). The liability to
endocarditis diminishes as age advances. The incidence of organic disease in
our cases was more than double in patients who had had their first attack below
the age of twenty years, compared with those with the first attack over twenty
years of age. It increases directly with the number of attacks. Of 116 cases,
in the first attack 58.1 per cent had endocarditis, 63 per cent in the second
attack, and 71 per cent in the third attack (Stephen Mackenzie). Thirty-five
per cent of our cases showed organic valve lesions, in 96 per cent the mitral
was involved, in 27 per cent the aortic, and in 33 per cent both the lesions
were combined. The mitral segments are most frequently involved and the
affection is usually of the simple, verrucose variety. Ulcerative endocarditis is
very rare. Of 209 cases of this disease which I analyzed, in only 24 did the
symptoms of a severe endocarditis arise during the progress of acute or sub-
acute rheumatism. The valvulitis in itself is rarely dangerous, producing few
symptoms, and is usu.ally overlooked. Unhappily, though the valve at the time
may not be seriously damaged, the inflammation starts changes which lead to
sclerosis and retraction of the segments, and so to chronic valvular disease.
Yenous thrombosis is an occasional complication.
{h) Pericarditis may occur independently of or together with endocarditis.
It may be simple fibrinous, sero-fibrinous, or in children purulent. Clinically
we meet it more frequently in connection with this disease than in any other
acute affection. It w^as present in 20 cases of our series — 6 per cent — in
only four of which did effusion occur. The physical signs are very charac-
teristic. The condition will be fully described under its appropriate section.
A peculiar form of delirium may develop during the progress of rheumatic
pericarditis.
(c) Myocarditis is most frequent in connection with endo-pericardial
changes. As Sturges insisted, the term carditis is applicable to many cases.
The anatomical condition is a granular or fatty degeneration of the heart-
muscle, which leads to weakening of the walls and to dilatation. It is not,
I think, nearly so common as the other cardiac aflEections. S. West has re-
224 SPECIFIC INFECTIOUS DISEASES.
ported instances of acute dilatation of the heart in rheumatic fever, in one
of which marked fatty changes were found in the heart-fibres.
(3) Pulmonary Affections. — Pneumonia and pleurisy occurred in 9.9-i
per cent of 3,433 cases (Stephen Mackenzie). They frequently accompany
the cases of endo-pericarditis. According to Howard's analysis of a large
number of cases, there were pulmonary complications in only 10.5 per cent
of cases of rheumatic endocarditis ; in 58 per cent of eases of pericarditis ; and
in 71 per cent of cases of endo-pericarditis. Congestion of the lung is occa-
sionally found, and in several cases has proved rapidly fatal.
(4) Nervous Complications. — These are due, in part, to the hyper-
pyrexia and in part to the special action upon the brain of the toxic agent
of the disease. They may be grouped as follows : (a) Delirium, associated
with the h}^erpyrexia or the toxaemia, may be active and noisy in character;
more rarely a low muttering delirium, passing into stupor and coma. It was
present in only five of our 307 cases, and in four of these we thought the sal-
icylates at fault. A peculiar delirium occurs in connection with rheumatic
pericarditis. It may be excited by the salicylate of soda, either shortly after
its administration, or more commonly a few days later, (h) Coma, which is
more serious, may occur without preliminary delirium or convulsions, and
may prove rapidly fatal. Certain of these cases are associated with hyper-
pyrexia; but Southey has reported the case of a girl who, without previous
delirium or high fever, became comatose, and died in less than an hour. A
certain number of such cases, as those reported by Da Costa, have been asso-
ciated with marked renal changes and were evidently ursemic. The coma may
supervene during the attack, or after convalescence has set in. (c) Convul-
sions are less common, though they may precede the coma. Of 127 observa-
tions cited by Besnier, there were 37 of delirirmi, only 7 of convulsions, 17 of
coma and convulsions, 54 of delirium, coma, and convulsions, and 3 of other
varieties (Howard), [d) Chorea. The relations of this disease and rheu-
matism will be subsequently discussed. It is sufficient here to say that in only
88 out of 554 cases which I have anah^zed from the Infirmary for Diseases of
the JSTervous System, Philadelphia, were chorea and rheumatism associated.
It is most apt to develop in the slighter attacks in childhood, (e) Meningitis
is extremely rare, though undoubtedly it does occur. It must not be forgot-
ten that in ulcerative endocarditis, which is occasionally associated with acute
rheumatism, meningitis is frequent. (/) Polyneuritis has been described. I
saw a remarkable case which followed hyperpyrexia. Free venesection saved
the patient's life. After many months the patient recovered, but with a
remarkable ataxia.
(5) Cutaneous Affections. — Sweat- vesicles have already been men-
tioned as extremely common. A red miliary rash may also develop. Scarla-
tiniform eruptions are occasionally seen. Purpura, with or without urticaria,
may occur, and various forms of erythema. It is doubtful whether the cases
of extensive purpura with urticaria and arthritis — ^peliosis rheumatica —
belong truly to acute rheumatism.
(6) Eheumatic Nodules. — These curious structures, described originally
by Meynet, occur in the form of small subcutaneous nodules attached to the
tendons and fasciae. Barlow and Warner, in England, and T. B. Futcher, in
the United States, have paid special attention to their varieties and impor-
RHEUMATIC FEVER. 225
tance. They vary in size from a small shot to a large pea, and are most
numerous on the fingers, hands, and wrists. They also occur about the elbows,
knees, the spines of the vertebrae, and the scapula. They are not often tender.
They are more common after the decline of the fever and in the children with
mitral valve disease. In only 5 of our patients were they present during the
acute attack. The nodules may grow with great rapidity and usually last for
weeks or months. They are more common in children than in adults, and in
the former their presence may be regarded as a positive indication of rheuma-
tism. They have been noted particularly in association with chronic rheumatic
endocarditis. Subcutaneous nodules occur also in migraine, gout, and arthri-
tis deformans. Histologically they are made up of round and spindle-shaped
cells. In addition to these firm, hard nodules, there occur in rheumatism and
in chronic vegetative endocarditis remarkable bodies, which have been called
by Fereol " nodosites cutanees ephemeres." In a case of chronic vegetative
endocarditis (without arthritis), which I saw with Dr. J. K. Mitchell, there
were, in addition to occasional elevated spots resembling urticaria, areas of
infiltration in the skin, from two to three lines in diameter, not elevated, but
pale pink, and exquisitely tender and painful even without being touched.
The course of acute rheumatism is extremely variable. It is, as Austin
Flint first showed, a self-limited disease, and it is not probable that medi-
cines have any special influence upon its duration or course. Gull and Sutton,
who likewise studied a series of 63 cases without special treatment, arrived at
the same conclusion.
Prognosis. — Rheumatic fever is the most serious of all diseases with a low
death-rate. The mortality is rarely above 3_.oi 3 per cent. Only 9 of our 330
patients died, 2.7 per cent, all with endocarditis and 6 with pericarditis.
Sudden death in rheumatic fever is due most frequently to myocarditis.
Herringham has reported a case in which on the fourteenth day there was
fatty degeneration and acute inflammation of the myocardium. In a few rare
cases it results from embolism. I saw one case at the Montreal General Hos-
pital in which we thought possibly the sudden death was due to Fuller's alka-
line treatment, which had been kept up by mistake. There was slight endo-
carditis but no myocardial changes. Alarming symptoms of depression
sometimes follow excessive doses of the salicylate of soda.
Diagnosis. — Practically, the recognition of acute rheumatism is very easy;
but there are several affections which, in some particulars, closely resemble it.
(1) Multiple Secondary Arthritis. — ^Under this term may be em-
braced the various forms of arthritis which come on or follow in the course of
the infective diseases, such as gonorrhoea, scarlet fever, dysentery, and cerebro-
spinal meningitis. Of these the gonorrhoea! form will receive special consid-
eration and is the type of the entire group.
(3) Septic Arthritis, which occurs in the course of pyaemia from any
cause, and particularly in puerperal fever. No hard and fast line can be
drawn between these and the cases in the first group ; but the inflammation
rapidly passes on to suppuration and there is more or less destruction of the
joints. The conditions under which the arthritis occurs give a clew at once
to the nature of the case. Under this section may also be mentioned :
(a) Acute necrosis or acuie osteo-myelitis, occurring in the lower end of
the femur, or in the tibia, and which may be mistaken for acute rheumatism.
16
226 SPECIFIC INFECTIOUS DISEASES.
Sometimes, too, it is multiple. The greater intensity of the local symptoms,
the involvement of the epiphyses rather than the joints, and the more
serious constitutional disturbances are points to be considered. The con-
dition is unfortunately often mistaken for acute arthritis, and, as the treat-
ment is essentially surgical, the error is one which may cost the life of the
patient.
(b) The acute artliritis of infants must be distinguished from rheuma-
tism. It is a disease which is usually confined to one joint (the hip or knee),
the effusion in which rapidly becomes purulent. The affection is most com-
mon in sucklings and is undoubtedly pygemic in character. It may also occur
in the gonorrhoeal ophthalmia or vaginitis of the new-born, as pointed out by
Clement Lucas.
(3) Gout. — While the localization in a single, usually a small, joint, the
age, the history, and the mode of onset are features which enable us to recog-
nize acute gout, there are everywhere many cases of acute arthritis, called
rheumatic fever, which are in reality gout. The involvement of several of
the larger joints is not so infrequent in gout, and unless tophi are present,
or unless a very accurate analysis of the urine is made, the diagnosis may be
difficult.
(4) Acute Arthritis Deformans. — In several cases I have mistaken
this form for rheumatic fever. It may come on with fever and multiple arthri-
tis, and for weeks there may be no suspicion of the true nature of the disease.
Gradually the fever subsides, but the periarticular thickening persists. As a
rule, however, in the acute febrile cases the involvement of the smaller joints,
the persistence; and the early changes in the articulations suggest arthritis
deformans.
Treatment. — The bed should have a smooth, soft, 3'et elastic mattress.
The patient shoidd wear a flannel night-gown, which may be opened all the
way down the front and slit along the outer margin of the sleeves. Three
or four of these should be made, so as to facilitate the frequent changes re-
quired after the sweats. He may wear also a light flannel cape about the
shoulders. He should sleep in blankets, not in sheets, so as to reduce the liabil-
ity to catch cold and obviate the unpleasant clamminess consequent upon heavy
sweating. Chambers insisted that the liability to endocarditis and pericarditis
was much reduced when the patients were in blankets.
Milk is the most suitable diet. It may be diluted with alkaline mineral
waters. Lemonade and oatmeal or barley water should be freely given. The
thirst is usually great and may be fully satisfied. There is no objection to
broths and soups if the milk is not well borne. The food should be given at
short and stated intervals. As convalescence is established a fuller diet may
be allowed, but meat should be used sparingly.
The local treatment is of the greatest importance. It often suffices to
wrap the affected joints in cotton. If the paui is severe, hot cloths may be
applied, saturated with Fullers lotion (carbonate of soda, 6 drachms; lauda-
num, 1 oz. ; glycerine, 2 oz. ; and water, 9 oz.) . Tincture of aconite or' chloral
may be employed in an alkaline solution. Chloroform liniment is also a good
application. Fixation of the joints is of great service in alla}dng the pain.
I have seen, in a German hospital, the joints enclosed in plaster of Paris,
apparently with great relief. Splints, padded and bandaged with moderate
RHEUMATIC FEVER. 22,1
firmness, will often be found to relieve pain. Friction is rarely well borne in
an acutely inflamed joint. Cold compresses are much used in Germany. The
application of blisters above and below the joint often relieves the pain. This
method, which was used so much a few years ago, is not to be compared with
the light application of the Paquelin thermo-cautery.
The drug treatment of acute rheumatism is still far from satisfactory,
though the introduction of the salicyl compounds has been a great boon.
Pribram's exhaustive consideration of the question, extending over some 67
pages (Nothnagel's Handbuch, Bd. v), in which he discusses some 75 drugs
and measures, indicates perhaps better than anything else that the therapeu-
tics of the disease are still far from satisfactory.
Treatment with the Salicyl Compounds. — Salicin, introduced in
1876 by Maclagan, may be used in doses of 20 grains every hour or two until
the pain is relieved. It has the advantage of being less depressing than the
salicylate of soda. It is also perhaps the best drug to use for children. Sali-
cylic acid, 15 to 20 grains, may be given every two hours in acute cases until
the pain is relieved. It is best given in capsules. Salicylate of soda, 20-grain
doses every two hours, is perhaps the best of the drugs for general use in the
acute rheumatism of adults. After the pain has been relieved, the drug should
be given every four or five hours until the temperature begins to fall. The
potassium bicarbonate may be given with it. Oil of wintergreen, 20 minims
every two hours in milk, may be used if the salicylate of soda disagrees. There
are many other salicyl compounds introdiiced of late, but the best results are h
obtained from the use of one or other of the above-named preparations. There
can be no question as to their efficacy in relieving the pain in the disease. A
majority of observers agree that they also protect the heart, shorten the course,
and render relapse less likely.
The Alkaline Treatment. — Potassium bicarbonate may be given in
half-drachm doses every three hours with the salicylic acid or salicin. Fuller's
plan was to give a drachm and a half of the sodium bicarbonate with half a
drachm of potassium acetate in three ounces of water, rendered effervescent at
the time of administration by half a drachm of citric acid or an ounce of
lemon-juice. When the urine is alkaline the amount may be reduced.
The heart should be watched carefully during the administration of full
doses of the alkalies.
A wide-spread popular belief attributes marvellous efficacy to bee-stings
in all sorts of rheumatism, and a formic-acid treatment has been introduced.
A 2| per cent solution is injected in the neighborhood of the painful joints.
Ainley Walker has collected (B. M. J., October 10, 1908) an interesting lit-
erature on the subject.
To allay the pain opium may be given in the form of Dover's powder,
or morphia hypodermically. Antipyrin, antifebrin, and phenacetin are useful
sometimes for the purpose. During convalescence iron is indicated in full
doses, and quinine is a useful tonic. Of the complications, hyperpyrexia
should be treated by the cold bath or the cold pack. The treatment of endo-
carditis and pericarditis and the pulmonary complications will be considered
under their respective sections.
To prevent and arrest endocarditis Caton urges the use of a series of small
blisters along the course of the third, fourth, fifth, and sixth intercostal nerves
228 SPECIFIC INFECTIOUS DISEASES.
of the left side, applied one at a time and repeated at different points. Potas-
sium or sodium iodide is given in addition to the salicylates. The patients
are kept in bed for about six weeks.
XX. CHOLERA ASIATICA.
Definition.— A specific, infectious disease, caused by the comma bacillus of
Koch, and characterized clinically by violent purging and rapid collapse.
Historical Summary. — Cholera has been endemic in India from a remote
period, but only within the last century did it make inroads into Europe and
America. An extensive epidemic occurred in 1832, in which year it was
brought in immigrant ships from Great Britain to Quebec. It travelled along
the lines of traffic up the Great Lakes, and finally reached as far west as the
military posts of the upper Mississippi. In the same year it entered the United
States by way of New York. There were recurrences of the disease in
1835-36. In 1848 it entered the country through I^ew Orleans, and spread
widely up the 'Mississippi Valley and across the continent to California. In
18-49 it again appeared. In 1854 it was introduced by immigrant ships into
New York and prevailed widely throughout the country. In 1866 and in 1867
there were less serious epidemics. In 1873 it again appeared in the United
States, but did not prevail widely. In 1884 there was an outbreak in Europe,
and again in 1892 and 1893. Although occasional cases have been brought by
ship to the quarantine stations in this country, the disease has not gained a
foothold here since 1873. It has prevailed in the Philippines, but is now, 1904,
well under control.
Etiology. — In 1884 Koch announced the discovery of the specific organ-
ism of this disease. Subsequent observations have confirmed his statement
that the comma bacillus, as it is termed, occurs constantly in the true cholera,
and in no other disease. It has the form of a slightly bent rod, which is
thicker, but not more than about half the length of the tubercle bacillus, and
sometimes occurs in corkscrew-like or S forms. It is not a true bacillus, but
really a spirochaete. The organisms grow upon a great variety of media and
display distinctive and characteristic appearances. Koch found them in the
water-tanks in India, and they were isolated from the Elbe water during the
Hamburg epidemic of 1892. During epidemics virulent bacilli may be found
in the faeces of healthy persons. The bacilli are found in the intestine, in the
stools from the earliest period of the disease, and very abundantly in the char-
acteristic rice-water evacuations, in which they may be seen as an almost pure
culture. They very rarely occur in the vomit. Post mortem, they are foimd
in enormous numbers in the intestine. In acutely fatal cases they do not seem
to invade the intestinal wall, but in those with a more protracted course they
are found in the depths of the glands and in the still deeper tissues. Experi-
mental animals are not susceptible to cholera germs administered per os. But
if introduced after neutralization of the gastric contents, and if kept in con-
tact with the intestinal mucosa by controlling peristalsis with opium, guinea-
pigs succumb after showing cholera-like S}Tnptoms. The intestines are filled
with thin, watery contents, containing comma bacilli in almost pure culture.
Cholera ToxI^^— Koch in his studies of cholera failed to find the spirilla
in the internal organs. He concluded that the constitutional symptoms of
CHOLERA ASIATICA. 229
the disease resulted from the absorption of toxic bodies from the intestine.
In old cholera cultures ptomaines are contained ; these probably have nothing
to do with the intoxication of human cholera. R. Pfeiffer has shown that the
cholera toxin is intimately associated with the proteid of the bacterial cells,
and, being of a very labile nature, can not be separated. Dead cultures are
toxic; and the symptoms produced by the introduction of even minimal
amounts are often comparable with those of the algid stage of cholera asiatica.
The symptoms occur very rapidly, and death often results in eight to twelve
hours ; in non-fatal cases recovery is often equally as rapid. The intracellular
cholera toxin is poisonous to animals if introduced into the blood, peritoneal
cavity, or subcutaneous tissues. No absorption takes place from the intestine
unless the epithelial layer has been injured.
Immunity. — From a recent careful study (1904) of the question of pro-
tective inoculation, E. P. Strong concludes that there is as yet no satisfactory
form of human protective inoculation, though the methods employed by Haff-
kine and Kolle promise good results.
Modes of Infection. — As in other diseases, individual peculiarities count
for much, and during epidemics virulent cholera bacilli have been isolated
from the normal stools of healthy men. Cholera cultures have also been swal-
lowed with impunity.
The disease is not highly contagious; physicians, nurses, and others in
close contact with patients are not often affected. On the other hand, wash-
erwomen and those who are brought into very close contact with the linen of
the cholera patients, or with their stools, are particularly prone to catch the
disease. There have been several instances of so-called " laboratory cholera,"
in which students, having been accidentally infected while working with the
cultures, have taken the disease, and at least one death has resulted from this
cause.
Vegetables which have been washed in the infected water, particularly let-
tuces and cresses, may convey the disease. Milk may also be contaminated.
The bacilli live on fresh bread, butter, and meat, for from six to eight days.
In regions in which the disease prevails the possibility of the infection of food
by flies should be borne in mind, since it has been shown that the bacilli may
live for at least three days in their intestines.
Infection through the air is not to be much dreaded, since the germs when
dried die rapidly.
The disease is propagated chiefly by contaminated water used for drink-
ing, cooking, and washing. The virulence of an epidemic in any region is in
direct proportion to the imperfection of its water-supply. In India the demon-
stration of the connection between drinking-water and cholera infection is
complete. The Hamburg epidemic is a most remarkable illustration. The
unfiltered water of the Elbe was the chief supply, although taken from the
river in such a situation that it was of necessity directly contaminated by
sewage. It is not known accurately from what source the contagion came,
whether from Russia or from France, but in August, 1893, there was a sud-
den explosive epidemic, and within three months nearly 18,000 persons were
attacked, with a mortality of 43.3 per cent. The neighboring city of Altona,
which also took its water from the Elbe, but which had a thoroughly well-
equipped modern filtration system, had in the same period only 516 cases.
230 SPECIFIC INFECTIOUS DISEASES.
Two main ij^es of epidemics of cholera are recognized : the first, in which
many individuals are attacked simultaneoiislv, as in the Hamburg outbreak,
and in which no direct connection can be traced between the individual cases.
In this type there is widespread contamination of the drinking-water. In the
other the cases occur in groups, so-called cholera nests; individuals are not
attacked simultaneously but successively. A direct connection between the
cases may be very difficult to trace. Again, both these t}-pes may be com-
bined, and in an epidemic which has started in a widespread infection through
water, there may be other outbreaks, which are examples of the second or
chain-like t}'pe.
Pettenkofer, on the other hand, denies the truth of this drinking-water
theory, and maintains that the conditions of the soil are of the greatest impor-
tance ; particularly a certain porosity, combined with moisture and contamina-
tion with organic matter, such as sewage. He holds that germs develop in
the subsoil moisture during the warm months, and that they rise into the
atmosphere as a miasm.
The disease always follows the lines of human travel. In India it has,
in many notable cases, been widely spread by pilgrims. It is carried also by
caravans and in ships. It is not conveyed through the atmosphere.
Places situated at the sea-level are more prone to the disease than inland
tovras. In high altitudes the disease does not prevail so extensively. A high
temperature favors the development of cholera, but in Europe and America
the epidemics have been chiefly in the late summer and in the autumn.
The disease affects persons of all ages. It is particularly prone to attack
the intemperate and those debilitated by want of food and by bad surroimd-
ings. Depressing emotions, such as fear, undoubtedly have a marked influence.
It is doubtful whether an attack furnishes immunitv" against a second one.
Morbid Anatomy. — A post-mortem diagnosis of the nature of the disease
could be made by any competent bacteriologist, as the micro-organisms are
specific and distinctive. The body has the appearances associated with pro-
found collapse. There is often marked post-mortem elevation of temperature.
The rigor mortis sets in early and may produce displacement of the limbs.
The lower jaw has been seen to move and the eyes to rotate. Various move-
ments of the arms and legs have also been noted. The blood is thick and
dark, and there is a remarkable diminution in the amount of its water and
salts. The peritongeum is sticky, and the coils of intestines are congested and
look thin and shrunken. The small intestine usually contains a turbid serum,
similar in appearance to that which was passed in the stools. The mucosa is,
as a rule, swollen, and in very acute cases slightly h}-perffimic ; later the con-
gestion, which is not uniform, is more marked, especially about the Peyer's
patches. Post mortem the epithelial lining is sometimes denuded, but this
is probably not a change which takes place freely during life. In the stools,
however, large numbers of columnar epithelial cells have been described by
Horner and others. The bacilli are found in the contents of the intestine
and in the mucous membrane. The spleen is usually small. The liver and
kidneys show cloudy swelling, and the latter extensive coagulation-necrosis and
destruction of the epithelial cells.
Symptoms. — A period of incubation of uncertain length, probably not more
than from two to five days, precedes the onset of the sj^nptoms.
CHOLERA ASIATICA. 231
Three stages may be recognized in the attack: the preliminary diarrhoea,
the collapse stage, and the period of reaction.
(a) The preliminary diarrhcea may set in abruptly without any pre-
vious indications. More commonly there are, for one or two days, colicky
pains in the abdomen, with looseness of the bowels, perhaps vomiting, with
headache and depression of spirits. There may be no fever.
(6) Collapse Stage. — The diarrhcea increases, or, without any of the
preliminary symptoms, sets in with the greatest intensity, and profuse liquid
evacuations succeed each other rapidly. There are in some instances griping
pains and tenesmus. More commonly there is a sense of exhaustion and col-
lapse. The thirst becomes extreme, the tongue is white; cramps of great
severity occur in the legs and feet. Within a few hours vomiting sets in and
becomes incessant. The patient rapidly sinks into a condition of collapse,
the features are shrunken, the skin has an ashy gray hue, the eyeballs sink
in the sockets, the nose is pinched, the cheeks are hollow, the voice becomes
husky, the extremities are cyanosed, and the skin is shrivelled, wrinkled, and
covered with a clammy perspiration. The temperature sinks. In the axilla
or in the mouth it may be from five to ten degrees below normal, but in the
rectum and in the internal parts it may be 103° or 104°, The pulse becomes
extremely feeble and flickering, and the patient gradually passes into a condi-
tion of coma, though consciousness is often retained until near the end.
The fseces are at first yellowish in color, from the bile pigment, but soon
they become grayish- white and look like turbid whey or rice-water; whence
the term " rice-water stools." There are found in them numerous small flakes
of mucus and granular matter, and at times blood. The reaction is usually
alkaline. The fluid contains albumin and the chief mineral ingredient is chlo-
ride of sodium. Microscopically, mucus and epithelial cells and innumerable
bacteria are seen, the majority of the latter being the comma bacilli.
The condition of the patient is largely the result of the concentration of
the blood consequent upon the loss of serum in the stools. There is almost
complete arrest of secretion, particularly of the saliva and the urine. On the
other hand, the sweat-glands increase in activity, and in nursing women it
has been stated that the lacteal flow is unaffected. This stage sometimes lasts
not more than two or three hours, but more commonly from twelve to twenty-
four. There are instances in which the patient dies before purging begins —
the so-called cholera sicca.
(c) Eeaction Stage. — When the patient survives the collapse, the cyano-
sis gradually disappears, the warmth returns to the skin, which may have for
a time a mottled color or present a definite erythematous rash. The heart's
action becomes stronger, the urine increases in quantity, the irritability of the
stomach disappears, the stools are at longer intervals, and there is no abdom-
inal pain. In the reaction the temperature may not rise above normal. Not
infrequently this favorable condition is interrupted by a recurrence of severe
diarrhcea and the patient is carried off in a relapse. Other cases pass into
the condition of what has been called cliolera-typlwid, a state in which the
patient is delirious, the pulse rapid and feeble, and the tongue dry. Death
finally occurs with coma. These symptoms have been attributed to uremia.
During epidemics attacks are found of all grades of severity. There are
cases of diarrhoea with griping pains, liquid, copious stools, vomiting, and
232 SPECIFIC INFECTIOUS DISEASES.
cramps, with slight collapse. To these the term cholerine has been applied.
They resemble the milder cases of cholera nostras. At the opposite end of the
series there are the instances of cholera sicca, in. which death may occur in
a few hours after the onset, without diarrha?a. There are also cases in which
the patients are overwhelmed with the poison and die comatose, without the
preliminary stage of collapse.
Complications and Sequelae.— The t>T3hoid condition has already been re-
ferred to. The consecutive nephritis rarely induces dropsy. Diphtheritic
colitis has been described. There is a special tendency to diphtheritic inflam-
mation of the mucous membranes, particularly of the throat and genitals.
Pneumonia and pleurisy may follow, and destructive abscesses may occur in
different parts. Suppurative parotitis is not very uncommon. In rare in-
stances local gangrene may occur. A troublesome sjinptom of convalescence
is cramps in the muscles of the arms and legs.
Dia^osis. — The only affection with which Asiatic cholera could be con-
founded is the cholera nostras, the severe choleraic diarrhoea which occurs
during the summer months in temperate climates. The clinical picture of the
two affections is identical. The extreme collapse, vomiting, and rice-water
stools, the cramps, the cyanosed appearance, are all seen in the worst forms of
cholera nostras. In enfeebled persons death may occur vrithin twelve hours.
It is of course extremely important to be able to diagnose between the two
affections. This can only be done by one thoroughly versed in bacteriological
methods, and conversant with the diversified flora of the intestines.
Attacks very similar to Asiatic cholera are produced in poisoning by
arsenic, corrosive sublimate, and certain fungi; but a difficulty in diagnosis
could scarcely arise.
The prognosis is always uncertain, as the mortality ranges in different
epidemics from .30 to 80 per cent. Intemperance, debility, and old age are
unfavorable conditions. The more rapidly the collapse sets in, the greater is
the danger, and as Andral truly says of the malignant form, " It begins where
other diseases end — in death.'"'* Cases vrith marked cyanosis and very low tem-
perature rarely recover.
Prophylaxis. — Preventive measures are all-important, and isolation of the
sick and thorough disinfection have effectually prevented the disease entering
England or the TTnited States since 1873. On several occasions since that
date cholera has been brought to various ports in America, but has been
checked at quarantine. During epidemics the greatest care should be exer-
cised in the disinfection of the stools and linen of the patients. When an
epidemic prevails, persons should be warned not to drink water unless pre-
viously boiled. Errors in diet should be avoided. As the disease is not more
contagious than t^-phoid fever, the chance of a person passing safely through
an epidemic depends very much upon how far he is able to carry out thor-
oughly prophylactic measures. , Digestive disturbances are to be treated
prompth', and particularly the diarrhcea, which so often is a preliminary s}anp-
tom. For this, opium and acetate of lead and large doses of bismuth should
be given.
Medicinal Treatment. — During the initial stage, when the diarrhoea is
not excessive but the abdominal pain is marked, opium is the most efficient
remedy, and it should be given hypodermically as morphia. It is advisable
YELLOW FEVER. 233
to give at once a full dose, which may be repeated on the return of the pain.
It is best not to attempt to give remedies by the mouth, as they disturb the
stomach. Ice should be given, and brandy or hot coffee. In the collapse stage,
writers speak strongly against the use of opium. Undoubtedly it must be
given with caution, but, judging from its effects in cholera nostras, I should
say that collapse per se was not a contra-indication. The patient may be
allowed to drink freely. For the vomiting, which is very difficult to check,
cocaine may be tried, and lavage with hot water. Creasote, hydrocyanic acid,
and creolin have been found useless. Eumpf advises calomel (gr. i) every
two hours.
External applications of heat should be made and a hot bath may be
tried. Warm applications to the abdomen are very grateful. Hypodermic
injections of ether will be found serviceable.-
Irrigation of the bowel — enteroclysis — with warm water and soap, or tan-
nic acid (2 per cent), should be used. With a long, soft-rubber tube, as much
as 3 or 4 litres may be slowly injected. Not only is the colon cleansed, but
the small bowel may also be reached, as sho-wm by the fact that the tannic-acid
solutions have been vomited.
Owing to the profuse serous discharges the blood becomes concentrated,
and absorption takes place rapidly from the lymph-spaces. To meet this,
intravenous injections were introduced by Latta, of Leith, in the epidemic
of 1832. My preceptor, Bovell, first practised the intravenous injections of
milk in Toronto, in the epidemic of 1854. A litre of salt solution at 107° may
be injected, and repeated in a few hours if no reaction follows. Less risky
and equally efficacious is the subcutaneous injection of a saline solution. For
this, common salt should be used in the proportion of about four grammes to
the litre. With rubber tubing, a cannula from an aspirator, or even with a
hypodermic needle, the warm solution may be allowed to run by pressure
beneath the skin. It is rapidly absorbed, and the process may be continued
until the pulse shows some sign of improvement. This is really a valuable
method, thoroughly physiological, and should be tried in all severe cases.
In the stage of reaction special pains should be taken to regulate the diet
and to guard against recurrences of the severe diarrhoea.
XXI. YELLOW FEVER.
Definition. — ^A fever of tropical and subtropical countries, characterized by
a toxaemia of varying intensity, with jaundice, albuminuria, and a marked ten-
dency to haemorrhage, especially from the stomach, causing the " black vomit."
The specific organism has not yet been found, but the disease is capable of
being transmitted through the bite of a mosquito, the Stegomyia fasciata.
Etiolog-y. — The disease prevails endemically in certain sections of the
Spanish Main. Until recently it has existed in Cuba, From these regions
it occasionally extends and, under suitable conditions, prevails epidemically
in the Southern States. Now and then it is brought to the large seaports of
the Atlantic coast. Formerly it occurred extensively in the United States.
In the latter part of the eighteenth century and the beginning of the nine-
teenth, frightful epidemics prevailed in Philadelphia and other jSTorthern
cities. The epidemic of 1793, in Philadelphia, so graphically described by Mat-
17
234 SPECIFIC INFECTIOUS DISEASES.
thew Carey, was the most serious that has ever visited any city of the Middle
States. The mortality, as given by Carey, during the months of August, Sep-
tember, Octol)er. and November, was 4,o4l, of whom 3,435 died in the months
of -September and October. The population of the city at the time was only
40,000. Epidemics occurred in the United States in 1797, 1798, 1799, and
in 1803, when the disease prevailed slightly in Boston and extensively in Balti-
more. In 1803 and 1805 it again appeared; then for many years the out-
breaks were slight and localized. In 1853 the disease raged throughout the
Southern States. There were moderately severe epidemics in 1867, 1873, and
1878; and still milder ones in 1897, 18*98, and 1899. In July, 1899, a local
outbreak occurred in the Soldiers' Home, at Hampton, Ya. There were 45
cases, with 13 deaths. In September. 1903, yellow fever became epidemic
along the Mexican side of the Eio Grande. It crossed into Texas and pre-
vailed in several of the border towns. In Laredo there were 1,014 cases, with
107 deaths. The efficient work of the public health service is shown by the
differences between 'Kew Laredo on the Mexican border, just across the river,
where 50 per cent of the population contracted the disease, and Laredo, Texas,
in which only 10 per cent out of a population of 10,000 were attacked. In
Europe it has occasionally gained a foothold, but there have been no wide-
spread epidemics except in the Spanish ports. The disease has existed on the
west coast of Africa. It is sometimes carried to ports in Great Britain and
France, but it has never extended into those countries. The history of the dis-
ease and its general SAinptomatolog}' are exhaustively treated of in the classical
works of Eene La Eoche and Berenger-Feraud.
Guiteras recognizes three areas of infection: (1) The focal zone in which
the disease is never absent, including Vera Cruz, Eio, and other Spanish- Amer-
ican ports. (2) The perifocal zone or regions of periodic epidemics, includ-
ing the ports of the tropical Atlantic in America and Africa. (3) The zone
of accidental epidemics, lying between the 35th and 45th parallels of north
latitude.
COXDITIOXS FAVORIXG THE DEVELOPMENT OF EPIDEMICS. Yellow fever
is a disease of the sea-coast, and rarely prevails in regions with an elevation
above 1,000 feet. Its ravages are most serious in cities, particularly when the
sanitary conditions are unfavorable. It is always most severe in the badly
drained, unhealthy portions of a city, where the population is crowded together
in ill-ventilated, dark houses. The disease prevails during the hot season.
Humidity and heat seem to be the proper coefficients for the preservation of
the poison.
The epidemics in the United States have always been in the summer and
autumn montlis, disappearing rapidly with the onset of cold weather.
Mode of Transmission. — Xo belief has been more strong among the laity
than tbat the disease is transmitted by infected clothing, and quarantine efforts
are chiefly directed to the disinfection of fomites of all sorts shipped from
infected ports. The remarkable series of experiments carried out by the Yel-
low Fever Commission of the United States Army, consisting of Drs. Walter
Eeed, Carroll, Lazear, and Agramonte, have demonstrated conclusively that
the disease can not be conveyed in this way. At Camp Lazear, Cuba, a frame
house was so constructed as to shut out the sunlight and fresh air, and the
vestibule was thoroughly screened. The average temperature for sixty-three
YELLOW FEVER. 235
days was kept about 76° F. Boxes filled with sheets, pillow-slips, blankets,
etc., contaminated by contact with cases of yellow fever and the discharges,
were placed in the house. Dr. K. P. Cooke and two privates of the hospital
corps, all non-immunes, entered this building and unpacked the boxes, and
for a period of twenty days occupied the room, each morning packing the
infected articles in the boxes, and at night unpacking them. In their experi-
ments with the fomites, seven, in all, non-immune subjects during the period
of sixty-three days lived in contact with the fomites and remained perfectly
well. These experiments, conducted in the most rigid and scientific man-
ner, completely discredit the belief in the transmission of the disease by
fomites.
Carlos Finlay, of Havana, in 1881 suggested that the disease was trans-
mitted by mosquitoes. Stimulated by the work of Eoss on malaria, the Amer-
ican Commission above-named has demonstrated conclusively that yellow fever
is transferred by a mosquito, Stegomyia fasciata, previously fed on the blood of
infected persons. The Commission showed also that in non-immunes the
disease could be produced by either the subcutaneous or the intravenous injec-
tion of blood taken from patients suffering with the disease.
An interval of about twelve days or more after contamination appears
to be necessary before the mosquito is capable of introducing the infection.
The bite at an early period after contamination does not confer immunity
against a subsequent attack. The period of incubation in 13 cases of experi-
mental yellow fever varied from forty-one hours to five days and seventeen
hours.
We must bear testimony to the heroism of the young soldiers who vol-
untarily, without compensation and purely in the interests of humanity, sub-
mitted to the experiments, and also to the zeal with which members of our
profession have, at great personal risk, attempted to solve the riddle of this
most serious disease. The death of Dr. Lazear, of the American Commission,
and of Dr. Myers, of the Liverpool Commission, adds two more names to the
already long roll of the martyrs of science. Major Gorgas carried out in
Havana sanitary measures based upon their reports, and stamped out the dis-
ease. No cases occurred from 1901 to 1904. Under Cuban control there was
a slight recrudescence in the island, but it has again been stamped out.
As Eeed points out, the mosquito theory fits in with well-recognized facts
in connection with the epidemics. After the importation of a case into an
uninfected region, a definite period elapses, rarely less than two weeks, before
a second case occurs. Like malaria, the disease prevails most during the mos-
quito season, and disappears with the appearance of frost. Probably, too, as
in very malarious districts, the disease is kept up by its prevalence in a very
mild form among children. As Guiteras remarks, " the foci of endemicity
are essentially maintained by the Creole infant population, which is subject
to the disease in a very mild form." In all probability the immunity which
is acquired by prolonged residence in a locality in which the disease is endemic
is due to the occurrence of very slight attacks.
One attack does not always confer immunity. Eosenau reports two attacks
within a period of eight years, and Libby two attacks within a period of two
years.
The specific germ has not yet been discovered.
236 SPECIFIC INFECTIOUS DISEASES.
Morbid Anatomy. —The skin is more or less jaundiced, even thougli the
patient did not appear yellow before death. Cutaneous hemorrhages may be
present. Xo specific or distinctive internal lesions have been found. The
blood-serum may contain haemoglobin, owing to destruction of the red cells,
just as in pernicious malaria. The heart sometimes, not invariably, shows
fatty change; the stomach presents more or less hj-persemia of the mucosa
with catarrhal swelling. It contains the material which, ejected during life,
is known as the hlacTc vomit. The essential ingredient in tliis is transformed
blood-pigment. There is often general glandular enlargement; the cervical
axillary and mesenteric groups are most involved. The liver is usually of a
pale yellow or brownish-yellow color, and the cells are in various stages of
fatty degeneration. From the date of Louis' observations at Gibraltar in 1828,
the appearances of this organ have been very carefully studied, and some have
thought the changes in it to be characteristic. Fatty degeneration and regions
of necrosis are present in all cases. The kidneys alwa3^s show traces of dif-
fuse nephritis. The epithelium of the convoluted tubules is swollen and very
granular; there may also be necrotic changes.
Symptoms. — The incubation is usually three or four daj'S; in 13 experi-
mental cases it ranged from forty-one hours to five days seventeen hours. The
onset is sudden, as a rule, without premonitory symptoms, and in the early
hours of the morning. Chilly feelings are common, and are usually associated
with headache and very severe pains in the back and limbs. The fever rises
rapidly and the skin feels very hot and dry. The tongue is furred, but moist ;
the throat sore. Nausea and vomiting are not constant, and become more
intense on the second or third day. The bowels are usually constipated. The
following, in detail,- are the more important characteristics :
Facies. — Even as early as the first morning the patient may present a
characteristic facies, one of the three distinguishing features of the disease,
which Guiteras describes as follows : The face is flushed, more so than in any
other acute infectious disease at such an early period. The eyes are injected,
the color is a bright red, and there may be a slight tumefaction of the e3'elids
and of the lips. Even at this early date there is to be noticed in connection
with the injection of the superficial capillaries of the face and conjunctivae a
slight icteroid tint, and " the early manifestation of jaundice is undoubtedly
the most characteristic feature of the facies of yellow fever."
The Fever. — On the morning of the first day the temperature may range
from 100° to 106°, usually it is between 102° and 103°. During the evening
of the first day and the morning of the second day the temperature keeps about
the same. There is a slight diurnal variation on the second and third day. In
very mild cases the fever may fall on the evening of the second or on the morn-
ing of the third day, or in abortive cases even at the end of twenty-four hours.
In cases that are to terminate favorably the defervescence takes place by lysis
during a period of two or three days. The remission or stage of calm, as it
has been called, is succeeded by a febrile reaction or secondary fever, which
lasts one, two, or three days, and in favorable cases falls by a short lysis. On
the other hand, in fatal cases the temperature is continuous, becomes higher
than in the initial fever, and death follows shortly.
The Pulse. — On the first day the pulse is rarely more than 100 or 110.
On the second or third day, whHe the fever still keeps up, the pulse begins
YELLOW FEVER. 237
to fall, as mTieh perhaps as 20 beats while the temperature has risen 1.5° or 2°.
On the evening of the third day there may be a temperature range of 103° and
a pulse of only 75, or " a temperature between 103° and 104° with a pulse
running from 70 to 80." This important diagnostic feature was first de-
scribed by Faget, of New Orleans. During defervescence the pulse may be-
come still lower, down to 50, 48, or 45, or even as low as 30 ; a slow pulse at
this period is not the special circulatory feature of the disease, but the slowing
of the pulse ivith a steady or even rising tem,perature.
Albuminuria. — This, the third characteristic symptom of the disease,
occurs as early as the evening of the third day. Guiteras says very truly that
it is very rare so early in other fevers except those of an unusually severe type.
"' Even in the mild cases that do not go to bed — cases of ' walking yellow fever '
— on the second, third, or fourth day of the disease albuminuria will show
itself." It may be quite transient. In the severer cases the amount of albu-
min is very large, and there may be numerous tube-casts and all the signs of
an acute nephritis; or complete suppression of the urine may supervene, and
death may occur in uremic convulsions or coma within twenty-four or thirty-
six hours.
GrASTRio Features. — " BlacJc Vomit." — Irritability of the stomach is pres-
ent from the very outset, and the vomited matter consists of the contents of
the stomach, and subsequently of mucus and a grayish fluid. In the third
stage of the disease the vomiting becomes more pronounced and in the severe
cases is characterized by the presence of blood. It may be copious and forci-
ble, producing much pain in the abdomen and along the gullet. There is
nothing specific in this " black vomit," which consists of altered blood, and
it is not necessarily a fatal symptom, though occurring only in the severer
forms of the disease. Other hgemorrhagic features may be present — petechias
on the skin and bleeding from the gums or from other mucous membranes.
The bowels are usually constipated, the stools not clay-colored, except late
in the disease. They are sometimes tarry from the presence of altered blood.
Mental Features. — In very severe cases the onset may be with active
delirium. " As a rule, in a majority of cases, even when there is black vomit,
there is a peculiar alertness; the patient watches ever3^thing going on about
him with a peculiar intensity and liveliness. This may be due in part to the
terror the disease inspires" (Guiteras).
Eelapses occasionally occur. Among the varieties of the disease it is impor-
tant to recognize the mild cases, characterized by slight fever, continuing for
one or two days, anc^ succeeded by a rapid convalescence. In the absence of a
prevailing epidemic, they would scarcely be recognized as yellow fever. Cases
of greater severity have high fever and the features of the disease are well
marked — ^vomiting, extreme prostration, and haemorrhages. And lastly, in the
malignant form the patient is overwhelmed by the intensity of the fever, and
death takes place in two or three days.
In severe cases convalescence may be complicated by parotitis, abscesses
in various parts of the body, and diarrhoea.
Diagnosis. — (a) From Dengue. — -The difficulty in the differential diag-
nosis of these two diseases lies in their frequent coexistence, as during the epi-
demic of 1897 in parts of the Southern States. During the autumn of 1897
the profession of Texas was divided on the question of Ihe existence of yellow
238 SPECIFIC INFECTIOUS DISEASES.
fever in the State, some claiming that the disease was dengue, others, includ-
ing Guiteras and West, that yellow fever also existed. In a majority of the
eases the three diagnostic points upon which Guiteras lays stress — the f acies,
the alhumiiniria, and the slowing of the pulse with maintenance or elevation
of the fever — are sufficient for the diagnosis. He states, too, that jaundice,
which does sometimes occur in dengue, rarely appears as early as the second
or third day of the disease, and on this much stress should be laid. Hem-
orrhages are much less common in dengue, but that they do occur has been
recognized by authorities even since the time of Eush.
(6) From Malarial Fever. — In the early stages of an epidemic cases
are very apt to be mistaken for malarial fever. In the Southern States the
outbreaks have usually been in the late summer months, the very season in
which the jestivo-autumnal fever prevails. Among the points to be specially
noted are the absence of early jaundice. Even in the most intense types of
malarial infection the color of the skin is rarely changed within four or five
days. To the experienced eye the facies would be of considerable help if the
case was seen from the outset. Albumin is rarely present in the urine so
early as the second day in a malarial infection. Other important points are
the marked swelling of the spleen in malaria, while in yellow fever it is not
much enlarged. Haemorrhages, and particularly the black vomit, epistaxis,
and bleeding gums are very rare in malarial infection. In the so-called h^em-
orrhagic malarial fever the jDatient has usually had previous attacks of malaria.
Hematuria is a prominent feature, while in yellow fever it is by no means
frequent. A special point of greater importance, perhaps, than any of these
general symptomatic features is the examination of the blood for the small,
ring-shaped organisms of the gestivo-autumnal infection. As a rule, their
presence is readily determined by any one familiar with their general charac-
ters. They are, however, of all forms the most difficult to recognize, and,
while very abundant in many cases, there are others in which they are ex-
tremely scanty in the peripheral circulation. The work of the army surgeons
in Cuba shows that in a large proportion of cases there is not much difficulty
in recognizing the gestivo-autumnal fever from yellow fever.
Prog'nosis. — In its graver forms, yellow fever is one of the most fatal of
epidemic diseases. The mortality has ranged, in various epidemics, from 15
to 85 per cent. In heavy drinkers and those who have been exposed to hard-
ships the death-rate is much higher than among the better classes. In the
epidemic of 1878, in Xew Orleans, while the mortality in hospitals was over
50 per cent of the white and 21 per cent of the colored patients, in private
practice it was not more than 10 per cent among the white patients. The
death-rate was very low in the epidemic of 1897.
Prophylaxis. — The measures carried out at Havana, already referred to,
and in the Canal Zone, Panama, by Major Gorgas illustrate the practical value
of scientific medicine. During 1905, the year after the American Commission
began work, yellow fever prevailed to the great demoralization of the em-
ployees, but it was gradually stamped out, and there have been no epidemics
for the past two years. The important measures are: (1) the protection of
the sick from the bites of mosquitoes; (2) the screening of houses, the use
of mosquito nets, and the destruction of the insects in the house; (3) meas-
ures such as already referred to under malaria, which diminish the possibility
THE PLAGUE. 239
of the mosquito breeding in the neighborhood of dwellings. New-comers
should be particularly careful in infected regions, and medical officers in
charge of camps should exercise the most scrupulous care to prevent the spread
of infection through mosquitoes.
Treatment. — Careful nursing and a symptomatic plan of treatment prob-
ably give the best results. The patient should be removed at once from the
infected house. Care should be taken to prevent chilling of the skin, and
sweating should be promoted. Bleeding has long since been abandoned. An
early purge, followed by phenacetin to relieve the backache, is recommended
by Geddings. Of special remedies quinine is warmly recommended, and,
when hsemorrhage sets in, the perchloride of iron. Digitalis, aconite, and
jaborandi have been employed. The fever is best treated by hydrotherapy.
There are several reports of the good effects of cold baths, sponging, and the
application of ice-cold water to the head and the extremities in this disease.
Vomiting is a very difficult symptom to control. Ice in small quantities is
probably the best remedy. Cocaine may be tried in doses of |-| gr. every
hour or two (Geddings).
We have no drug which can be depended upon to check the haemorrhages.
Ergot and acetate of lead and opium are recommended. The urgemic symp-
toms are best treated by the hot bath. Stimulants should be given freely dur-
ing the second stage, when the heart's action becomes feeble and there is a
tendency to collapse. The patient should be carefully fed; but when the
vomiting is incessant it is best not to irritate the stomach, but to give nutri-
tive enemata until the gastric irritation is allayed. Washing out the lower
bowel is very advantageous, and in the cases with extreme toxaemia the sub-
cutaneous or intravenous injection of saline solution may be tried.
XXII. THE PLAGUE.
Definition. — A specific, infectious disease, caused by Bacillus pestis, char-
acterized by inflammation of the lymphatic glands (buboes), carbuncles, pneu-
monia, and often haemorrhages.
History and Geographical Distribution. — The disease was probably not
known to the classical Greek writers. The earliest positive account dates
from the second century of our era. The plague of Athens and the pestilence
of the reign of Marcus Aurelius were apparently not thia disease (Payne).
From the great plague in the days of Justinian (sixth century) to the middle
of the seventeenth century epidemics of varying severity occurred in Europe.
Among the most disastrous was the famous " black death " of the fourteenth
century, which overran Europe and destroyed a fourth of the population. In
the seventeenth century it raged virulently, and during the great plague of
London, in 1665, about 70,000 people died. During the eighteenth and nine-
teenth centuries the ravages of the disease lessened.
The revival of plague is the most important single fact in epidemiology
of the past decade. Throughout the nineteenth century it waned progress-
ively, outbreaks of some extent occurring in Turkey and Asia Minor and
Astrakan, but we had begun to place it with sweating siclcness and typhus
among the diseases of the past. We knew that it slumbered in parts of
China, and in northwest India, but the epidemic of 1894 at Hong-Kong
240 SPECIFIC INFECTIOUS DISEASES.
showed that the " hlaek death " was still virulent. Since then it has spread
in an ominous manner, reaching India, China, French Indo-China, Japan,
Formosa, Australia, the Philippine Islands, South America, the West Indies,
the United States, Cape Colony, Madagascar, Egypt, Asia Minor, and Eussia
in Asia. In Europe, cases have heen carried to Marseilles and other Medi-
teri'ancan ports and to Hamburg and Glasgow. In the latter city there was
a small outbreak in 1900, 36 cases. In the next year there were two cases
and in 1907 two cases — this without fresh importation. In San Francisco
there has been, 1907-1908, a recrudescence of the disease, and to March 15,
190S, tliere were 121 cases with 77 deaths. In India the ravages continue
unabated — more than a million deaths were caused by it in 1907, chiefly in
the Punjab, and the plague problem of that country is one of extraordinary
complexity. To Simpson's Croonian lectures, 1907, the student is referred
for full information. He thus emphasizes the danger of the situation: The
feature of the present pandemic that presages danger in the future is the
marvellous powers of recrudescence and resistance to all known measures of
prevention, even when the cases are few, as in Glasgow and San Francisco.
The slight mortality and the small number of cases lull the authorities into a
dangerous frame of mind, as at any time the conditions — ^unknown at present
— may arise which enable it to develop into a wide-spread epidemic. The dis-
ease may be kept in check, but the danger remains while the rats are infected.
Etiology. — The specific organism of the disease is a bacillus discovered
by Kitasato. It resembles somewhat the bacillus of chicken cholera, and grows
in a perfectly characteristic manner. Bacillus pestis occurs in the blood and
in the organs of the body, and has also been found in the dust and in the soil
of houses in which the patients have lived.
The disease prevails most frequently in hot seasons, though an outbreak
may occur during the coldest weather. Persons of all ages are attacked. It
spreads chiefly among the poor, in the slums of the great cities.
The following are the conclusions of the Plague Commission (1908) : 1.
Contagion occurs in less than 3 per cent of the cases, playing a very small part
in the general spread of the disease. 2. Bubonic plague in man is entirely
dependent on the disease in the rat. 3. The infection is conveyed from rat
to rat and from rat to man solely by means of the rat-flea. 4. A case in man
is not in itself infectious. 5. A large majority of cases occur singly in houses.
AVhen more than one case occurs in a house, the attacks are generally nearly
simultaneous. 6. Plague is usually conveyed from place to place by imported
rat-fleas, which are carried by people on their persons or in their baggage.
The human agent may himself escape infection. 7. Insanitary conditions
have no relation to the occurrence of plague, except in so far as they favor
infestation by rats. 8. The non-epidemic season is bridged over by acute
plague m the rat, accompanied by a few cases among human beings.
Clinical Forms.— Pestis Mixoe.— In this variety, also known as the am-
bulant, tlie patient has a few days of fever, with swelling of the glands of the
grom, and possibly suppuration. He may not be ill enough to seek medical
relief. These cases, often found at the beginning and end of an epidemic,
are a very serious danger, as the urine and faeces contain bacilli.
Bubonic Plague.— This constitutes the common variety, 77 65 per cent
of 11,600 cases of plague treated in the Arthur Road Hospital, Bombay
THE PLAGUE. 241
(N. H. Choksy). The stage of invasion is characterized by headache, hack-
ache, stiffness of the limbs, a feeling of anxiety and restlessness, and great
depression of spirits. There is a steady rise in the fever until the evening of
the third or fourth day, when there is a drop of two or three degrees. There
is then a secondary fever, as some writers describe it, in which the tempera-
ture reaches a still higher point. The tongue becomes brown, collapse symp-
toms are apt to supervene, and in very severe infections the patient may die
at this stage. In at least two-thirds of all cases there are glandular swellings
or buboes. An analysis of 9,500 cases of buboes gave more than 54 per cent
with the glands of the groin affected. The swelling appears usually from the
third to the fifth day. Eesolution may occur, or suppuration, or in rare cases
gangrene. Suppuration is a favorable feature, as noted by De Foe in his
graphic account of the London plague.
Petechige very commonly show themselves, and may be very extensive.
These have been called the " plague spots,'^ or the " tokens of the disease," and
gave to it in the middle ages the name of the Black Death. Haemorrhages
from the mucous membranes may also occur; in some epidemics haemoptysis
has been especially frequent.
Septicemic Plague. — In this, the most rapid form, the patient succumbs
in three or four days with a virulent infection before the buboes appear. 'This
form constituted 14.25 per cent of the 11,600 cases. Hsemorrhages are com-
mon. The bacilli can be obtained from the blood.
Pneumonic Plague. — This remarkable variety presents the features of
a pneumonia, and the sputum contains the bacilli in enormous numbers. It
is even more fatal than the septicgemic type. The mortality in 514 cases was
96.69 per cent. It is of short duration. The fever is high, the respirations
rapid, the pneumonia is chiefly lobular, the sputa hgemorrhagic, and contain
the bacilli in almost pure culture.
In other varieties the chief manifestations may be in the skin and subcu-
taneous tissues, or in the intestines, causing diarrhoea and sometimes the
features of typhoid fever.
Diagnosis. — At the early stage of an outbreak plague cases are easily over-
looked, but if the suspicious cases are carefully studied by a competent bac-
teriologist, there is no disease which can be more positively identified. The
San Francisco epidemic illustrates this. The nature of the cases was recog-
nized by Kellog and by Kinyoun, but with an amazing stupidity (which was
shared by not a few physicians, who should have known better) the Governor
of the State refused to recognize the presence of plague, and the United States
Government had to intervene and send a board of experts to settle the ques-
tion. In the early Glasgow cases Colvin, while suspecting typhoid fever, saw
that there was something unusual, and at once took precautionary measures.
Probably, too, the association of four cases in one family made him suspicious.
The limitation of the outbreak was due to the prompt and effective measures
taken by A. K. Chalmers and his associates. The widespread prevalence of
the disease makes it the imperative duty of the health authorities to have on
hand, in connection with large ports, skilled men who can promptly make the
bacteriological diagnosis. There are dangers from the cultures in laboratories,
as shown by the experiences of Vienna and Ann Arbor, but with proper precau-
tions they may be reduced to a minimum.
242 SPECIFIC INFECTIOUS DISEASES.
Prophylaxis. — Wherever plague exists an organized staff, an intelligent
policy, and a long purse are needed. In India, where fifteenth-century con-
ditions prevail, and where the scale of the epidemic is so enormous, the prob-
lem of prophylaxis looks hopeless. Simpson's recommendation of a specially
trained plague service, organized on proper lines and on a liberal basis, should
be carried out. Quarantine, to be of any value, must be most vigorous. A
most important prophylactic measure relates to the destruction of rats, which
are the chief agents in the distribution of the disease. As Ashburton Thomp-
son remarks (Eeport on Plague at Sydney), "during an epidemic the only
proceeding of much value is destruction of rats and of their nests, burrows,
and liabitual liaunts, and those others which are calculated to prevent access
of surviving rats to proximity with human beings — in other words, to expel
them from occupied premises, and to keep them outside. . . . On premises
where indigenous cases had occurred, moreover, the presence of freshly deceased
rats was discovered quite often enough to support the general proposition that
the danger of contracting plague stood in relation to the presence of rats in
dwellings or inclosed premises. A general slaughter of rats would answer the
purpose, if it could be carried out quickly and with tolerable completeness."
Koch recommends the breeding of improved strains of cats as fitted most
naturally for the task.
Treatment. — In a disease the mortality of which may reach as high as 80
or 90 per cent the question of treatment resolves itself into making the patient
as comfortable as possible, and following out certain general principles such
as guide us in the care of fever patients. Cantlie recommends purgation and
stimulation from the outset, and the use of morphia for the pain. The local
treatment of the buboes is important. Ice may be applied to them, and good
results apparently follow the injection of the bichloride of mercury. The
pyrexia of the disease is best treated by systematic hydrotherapy.
A plague serum, chiefly the Lustig and the Yersin-Eouse, has been used.
Choksy has collected the statistics to date (1907), 1,408 cases, with a mortal-
ity of 53.3 per cent. Of those treated on the first day the death-rate was only
28.9. Choksy concludes that a reduction of 20-25 per cent in the mortality
may be obtained by its use.
Preventive Inoculation.— With Haffkine's serum in 12 districts, of
224,228 persons inoculated, 3,399 took the disease; of 639,600 uninoeulated,
49,430 were attacked. C. J. Martin concludes that the chances of subsequent
infection are reduced four-fifths, and the chances of recovery are two and a
half times as great as in the case of the uninoeulated.
XXIII. BACILLARY DYSENTERY.
Definition.— A form of intestinal flux, usually of an acute type, occurring
sporadically and in severe epidemics, attacking children as well as adults
characterized by pain, frequent passages of blood and mucus, and due to the
action^ of a specific bacillus, of which there are various strains.
Etiology.— Owing to improved sanitation, dysentery has become less fre-
quent. In temperate climates sporadic cases occur from time to time, and at
intervals epidemics prevail, particularly in overcrowded institutions. The sta-
tistics of general hospitals for the past twenty years show a decided decrease
BACILLARY DYSENTERY. 243
in the number of cases admitted. Eecords of widespread epidemics have been
collected by Woodward. The most serious was that which prevailed from 1847
to 1856. In Great Britain and Ireland epidemics of the disease have become
less frequent. In institutions, particularly in overcrowded asylums, dysen-
tery is very common, and this form has been made the subject of a valuable
report by Mott and Durham. In the tropics " dysentery is a destructive
giant compared to which strong drink is a mere phantom" (Macgregor).
Dysentery is one of the great camp diseases, and it has been more destructive
to armies than powder and shot. In the Federal service during the civil war,
according to Woodward,* there were 259,071 cases of acute and 28,451 cases
of chronic dysentery. The disease prevails in Porto Eico, the Philippines,
and to a less extent in Cuba. In the South African campaign dysentery pre-
vailed widely. For many years a very fatal form of dysentery has prevailed
in Japan, particularly in the summer and autumn months, having a mortality
of from 26 to 27 per cent; in 1899 there were 125,989 cases, with 26,709
deaths (Eldridge). It is now generally conceded that the severe epidemics
of acute dysentery occurring in the tropics are of the bacillary type, and the
same form prevails in temperate climates.
Bacillus Dysenteric. — In 1898, Shiga, a Japanese observer, found in
the dysentery prevailing in his country a bacillus with special characters, which
he considered to be the specific cause of the disease.
Flexner and Barker, of the Johns Hopkins Commission for the Study of
Tropical Diseases, found in the dysentery in the Philippine Islands an iden-
tical organism, and it has been made the subject of very careful study by Flex-
ner, and also by K. P. Strong, Musgrave, and Craig, of the United States
army. It has also been found in cases of dysentery from Porto Rico. The
organism appears to be constantly present in the acute dysentery of the tropics.
In Manila, according to Strong and Musgrave, of 1,328 cases, 712 were of the
acute specific variety, 55 suspected specific cases, and 561 of amoebic dysentery.
Kruse, in an outbreak at Laar, in Germany, in which 300 persons were at-
tacked, has isolated an identical bacillus. Vedder and Duval demonstrated
that sporadic cases in adults in Philadelphia, as well as epidemics of dysen-
tery in the Lancaster County Asylum, Pennsylvania, and in the almshouse at
New Haven, were due to this organism. During the summer of 1902 Duval
and Bassett, working at the Mount Wilson Sanitarium, first demonstrated that
certain forms of summer diarrhoeas of infants were due to infection with
B. dysenterige. The Rockefeller Institute, during the following summer, con-
ducted a collective investigation into the cause of infantile diarrhoeas in Bos-
ton, New York, Philadelphia, and Baltimore. Several observers, under Flex-
ner's direction, studied 412 cases and found the dysentery bacillus present in
279 or 63.2 per cent. Spronck, working in Holland, also confirmed these
observations.
The strain of the bacillus most frequently found in the United States is
the " Flexner-Harris " type.
It is now conceded that a number of strains of the bacillus occur. This
fact has been determined by the relative agglutinative power of immune serum
* Medical and Surgical History of the War of the Rebellion, Medical, vol. ii. The most
exhaustive treatise extant on intestinal fluxes — an enduring monument to the industry and
ability of the author.
244 SPECIFIC INFECTIOUS DISEASES.
upon the bacilli isolated, as well as by the action of the latter upon various
sugars. Flexner recognizes three types: (1) "Shiga" tj^e: attacks glucose,
without action on other sugars, including mannite and lactose. (2) " Flex-
ner-Harris" type: attacks glucose, mannite, and dextrine; does not attack
lactose. (3) Bacillus " Y " (Hiss and Eussell) : attacks glucose and mannite;
no action on dextrine and lactose. The lesions produced by the different
strains are identical. The organism agglutinates ^^•ith the blood serum of
cases with acute dysentery as well as with the serum of immunized animals.
As yet nothing is Icnown as to how infection of human beings occurs. Its
habitat is unknown, and the organism has never been isolated from sources
outside the human body. In two instances the dysentery bacillus has been
isolated by Duval from the stools of healthy children. In dysenteric stools the
organism is most readily isolated from the particles of mucus.
Morbid Anatomy. — In the acute cases, when death has occurred on the
fourth to the seventh day, the mucous membrane of the large intestine is
swollen, of a deep-red color, and presents elevated, coarse corrugations and
folds. In addition to the intense h}^er£emia there are spots of hsemorrhages
scattered through the swollen mucosa. Over the surface there is usually a
superficial necrotic layer, which can be brushed off lightly with the finger.
This may be in patches, or uniform over large areas. There is no ulceration,
only the superficial, general necrosis of the mucosa. The solitary follicles are
swollen and red, but the prominence is obscured in the involvement of the
entire mucosa. In cases of great intensity the entire coats of the colon may
be stiff and thick, and the mucous membrane enormously increased in thick-
ness, grayish-black in color, extensivel}^ necrotic, and, in places, gangrenous.
The serous surface is often deeply injected. The ileum is, in many cases,
involved, having a deeply hgemorrhagic mucosa, with a superficial necrosis.
In the subacute cases there is not the same great thickening of the intestinal
wall, the solitar}' follicles are more swollen, there is less necrosis, and, while
there are no ulcers, there are superficial erosions.
Symptoms. — According to Strong and Musgrave, the period of incubation
is not more than forty-eight hours. The onset, which is usually sudden, is
characterized by slight fever, pain in the abdomen, and frequent stools. At first
mucus is passed, but within twenty-four hours blood appears with it, or there is
pure blood. There is a constant desire to go to stool, T\dth great straining and
tenesmus ; every hour or half hour there may be a small amount of blood and
mucus passed. The temperature rises and may reach 103° or 10J:°. The pulse
increases in frequency, and in the severer cases becomes very small. The
tongue is coated with a white fur, and there is excessive thirst. In the very
acute cases the patient becomes, seriously ill within fort3^-eight hours, the move-
ments increase in frequency, the pain is of great intensity, the patient becomes
delirious, and death may occur on the third or fourth day. In cases of moder-
ate severity the urgency of the s}Tnptoms abates, the stools lessen, the tem^
perature falls, and within two or three weeks the patient is convalescent. The
mortality in the severe forms is very high. There is a subacute form which
lasts for many weeks or months. The patients become greatly emaciated,
having from three to five stools in the twenty-four hours. The bacillus
dysenterige is found in the stools, and it agglutinates readily with the blood
serum.
BACILLARY DYSENTERY. 245
Other Clinical Types. — The foregoing account describes the essential fea-
tures of bacillary dysentery as seen in Japan, the Philippines, and the tropics.
The clinical features of bacillary dysentery in adults in temperate climates
differ in no essential manner from those already described. Although the
evidence hardly warrants us at present in making the sweeping statement that
all non-amoebic cases of dysentery in this country are bacillary in origin, yet
experience will probably demonstrate eventually that this is the case. What
is known as the acute catarrhal dysentery is probably a sporadic form due to
the Bacillus dysenteries. What is known as diphtheritic dysentery is a type
of the bacillary form with great necrosis and infiltration of the mucosa. The
secondary diphtheritic dysentery is a common terminal event in many acute
and chronic diseases. Vedder and Duval have demonstrated that the bacillus
is present in these cases.
Complications and Sequelae.— Penfoni^is is rare, due either to extension
through the wall of the bowel or to perforation. When this occurs about the
csecal region, perityphlitis results ; when low down in the rectum, periproctitis.
In 108 autopsies collected by Woodward perforation occurred in 11. Abscess
of the liver, so common iq the amoebic form, is very rare. It is interesting to
note, as illustrating the probable type of the disease, how comparatively rare
abscess of the liver was during the civil war. Very few cases occurred in the
South- African War (Eolleston).
In the tropics malaria and acute dysentery very often coexist. With refer-
ence to typhoid fever, as a complication. Woodward mentions that the com-
bination was exceedingly frequent during the civil war, and characteristic
lesions of both diseases coexisted. In civil practice it is extremely rare.
Sydenham noted that dysentery was sometimes associated with rheumatic
pains, and in certain epidemics joint swellings have been especially prevalent.
They are probably not of the nature of true rheumatism, but rather analogous
to those of gonorrhceal arthritis. In severe cases there may be pleurisy, throm-
bosis, pericarditis, endocarditis, and occasionally pysemic manifestations,
among which may be mentioned pylephlebitis. Chronic Bright's disease is
also an occasional sequel. In protracted cases there may be an ansmic oedema.
An interesting sequel of dysentery is paralysis. Woodward reports 8 eases.
Weir Mitchell mentions it as not uncommon, occcurring chiefly in the form
of paraplegia. As in other acute fevers, this is due probably to a neuritis.
Kemlinger, in two cases of non-amoebic dysentery in Tunis, observed an epi-
didymitis during convalescence. Gonorrhoea was excluded. In a third case
the dysentery was complicated by an abscess of the spleen, which ruptured,
causing death. Intestinal stricture is a rare sequence — so rare that no case
was reported at the Surgeon- General's office during the civil war. Among the
sequelae of chronic dysentery, in persons who have recovered a certain measure
of health, may be mentioned persistent dyspepsia and irritability of the bowels.
Diagnosis. — In the acute specific form the blood-serum agglutinates the
dysentery bacillus. The " Flexner-Harris " type of the organism agglutinates
in dilutions of from 1 to, 1,000 up to 1 to "l,500. This is the form of the
organism that prevails in the United States. The " Shiga " type agglutinates
less readily. The blood-serum of a dysenteric patient will agglutinate both
types, but the former more readily than the latter. In all non-amoebic dys-
enteries efforts should be made to 'isolate the dysentery bacillus from the stools.
246 SPECIFIC INFECTIOUS DISEASES.
Treatment.— Flint has showa. that sporadic dysentery is, in its slighter
grades at least, a self-limited disease, which runs its course in eight or nine
days. Heading the report of his cases, one is struck, however, with their com-
parative mildness.
Prophylactic. — We are as yet ignorant of the sources of infection. The
dysentery bacillus has not been found outside the human body. It seems quite
possible that it is a water-borne organism, and the same proph3'lactic pre-
cautions should be followed as are adopted in t}^hoid fever. Flexner and
Gay have shown that animals can be protected from infection by a previous
treatment with immune horse serum. Immunization of human individuals
has not been so far demonstrated.
Medicinal. — The enormous surface involved, amounting to many square
feet, the constant presence of irritating particles of food, and the impossibility
of getting absolute rest, are conditions which render the treatment of dysen-
tery peculiarly difficult. Moreover, in the severer cases, when necrosis of the
mucosa has occurred, ulceration necessarily follows, and .can not in any way
be obviated. When a case is seen early, particularly if there has been consti-
pation, a saline purge should be gi^en. The free watery evacuations produced
by a dose of salts cleanse the large bowel with the least possible irritation, and
if necessary, in the course of the disease, particularly if scybala are present,
the dose may be repeated. The saline treatment is much commended. W. J.
Buchanan has treated 855 cases with only 9 deaths. He gives a drachm of
sodium sulphate, four, six, or eight times a day, and continues until all blood
and mucus have disappeared, usually for two or three days. Of medicines
which are supposed to have a direct effect upon the disease, ipecacuanha still
maintains its reputation in the tropics. Xo food is taken for three hours,
then twenty drops of laudanum, and half an hour after from 20 to 60 grains
of ipecacuanha. If rejected by vomiting, the dose is repeated in a few hours.
Washbourne and Eichards, in the South African campaign, speak of the good
results of ipecacuanha combined with the saline treatment.
Minute doses of corrosive sublimate, one hundredth of a grain ever}^ two
hours, are warmly recommended by Einger. Large doses of bismuth, half a
drachm to a drachm every two hours, so that the patient may take from 12 to
15 drachms in a day, have in many cases had a beneficial effect. To do good
it must be given in large doses, as recommended by Monneret, who gave as
high as 70 grammes a day. It certainly is more useful in the chronic than
the acute cases. It is best given alone. Opium is an invaluable remedy for
the relief of the pain and to quiet the peristalsis. It should be given as mor-
phia, hypodermically, acccording to the needs of the patient.
The treatment of dysentery by topical applications is by far the most
rational plan. A serious obstacle, however, in the acute cases, is the extreme
irritability of the rectum and the tenesmus which follows any attempt to irri-
gate the colon. A preliminary cocaine suppository or the injection of a small
quantity of the 4-per-cent solution will sometimes relieve this, and then with
a long tube the solution can be allowed to flow in slowly. The patient should
be in the dorsal position with a pillow under the hips, so as to get the effect
of gravitation. Water at the temperature of 100° is very soothing, but the
irritability of the bowel is such that large quantities can rarely be retained for
any time. When the acute symptoms subside, the injections are better borne.
MALTA FEVER. 247
Various astringents may be used — alum, acetate of lead, sulphate of zinc and
copper, and nitrate of silver. Of these remedies the nitrate of silver is the
best, though, I think, not in very acute cases. In the chronic form it is per-
haps the most satisfactory method of treatment which we have. It is useless
to give it in the small injections of two or three ounces with 1 to 2 grains of
the salt to the ounce. It must be a large irrigating injection, which will reach
all parts of the colon. This plan was introduced by Hare, of Edinburgh, and
is highly recommended by Stephen Mackenzie and H. C. Wood. The solu-
tion must be fairly strong, 20 to 30 grains to the pint, and if possible from
3 to 6 pints of fluid must be injected. To begin with it is well to use not
more than a drachm to the 2 pints or 2^ pints, and to let the warm fluid run
in slowly through a tube passed far into the bowel. It is at times intensely
painful and is rejected at once. Argyrm, so far as I know, has never followed
the prolonged use of nitrate-of-silver injections in chronic dysentery. When
there is not much tenesmus, a small injection of thin starch with half a drachm
to a drachm of laudanum gives great relief, but for the tormina and tenesmus,
the two most distressing symptoms, a hypodermic of morphia is the only satis-
factory remedy. Local applications to the abdomen, in the form of light
poultices or turpentine stupes, are very grateful.
The diet in acute cases must be restricted to milk, whey, and broths, and
during convalescence the greatest care must be taken to provide only the most
digestible articles of food. In chronic dysentery, diet is perhaps the most
important element in the treatment. The number of stools can frequently
be reduced from ten to twelve in the day to two or three, by placing the patient
in bed and restricting the diet. Many cases do well on milk alone, but the
stools should be carefully watched and the amount limited to that which can
be digested. If curds appear, or if much oily matter is seen on microscopical
examination, it is best to reduce the amount of milk and to supplement it with
beef-Juice or, better still, egg-albumen. The large doses of bismuth seem
specially suitable in the chronic cases, and the injections of nitrate of silver,
in the way already mentioned, should always be given a trial.
Serum Therapy. — Shiga produced a polyvalent serum by immunizing
horses, by which he claims to have reduced the mortality in " endemic " dysen-
tery in Japan from about 35 per cent to 9 per cent. The encouraging early
results of this form of treatment have not apparently been borne out by subse-
quent experience. Flexner has immunized horses, and this immune-serum has
been given a fair trial in the treatment of infantile diarrhoeas of bacillary ori-
gin. The investigation was carried on under the direction of the Eockefeller
Institute. Holt reports that the anti-dysenteric serum was employed in 83
cases, 38 of which proved fatal. He states that on the whole the results were
disappointing. In only 12 cases did a noteworthy improvement appear to
follow its administration.
XXIV. MALTA FEVER.
(TTndulant Fever, Mediterranean Fever.)
Definition. — An endemic fever, characterized by an irregular course, undu-
latory pyrexial relapses, profuse sweats, rheumatic pains, arthritis, and an
enlarged spleen. An organism. Micrococcus melitensis, is present in all cases.
248 SPECIFIC INFECTIOUS DISEASES.
Distribution.— Tlie disease prevails in the Mediterranean littoral, and en-
demic foci exist in India, Africa, China, and Manila. In the Malta garrison
in the seven years 1898-1904, there were 2,229 cases, with an average case
duration of one hundred and twenty days and with 77 deaths. About the same
number of cases occurred in the fleet.
Etiology. — Tlie greater part of our knowledge of this remarkable disease
we owe to tlie work of British army surgeons stationed at Gibraltar and Malta,
particularly to Marston, Bruce, and Hughes. In 1886 iBruce isolated an or-
ganism which he called Micrococcus meUtensis from the spleen and blood.
Hughes, Wright, and others confirmed this. Much work was done to establish
tlie specificity of the organism. In 1904-1905 a Government Commission be-
gan a study on the island of the problems of the disease in all its aspects. It
was shown to be a septicemia, due to the above-named organism, which had
an unusually prolonged saprophytic existence. Zamit showed that the goats,
the most important animals in the domestic life' of Malta, were largely infected,
from 10 to 15 per cent having the micrococcus in their milk. Monkeys were
successfully infected with milk which contained the organisms. Steps were at
once taken to stop the use as far as possible of goat's milk for the troops, with
the result that the number of cases fell from 750 in 1905 to 145 in 1906, and
to 7 for nine months of 1907. There were no cases in 1907 in the Mediter-
ranean fleet. Eyre has brought forward evidence to show that the disease may
be transmitted by mosquito bites.
Symptoms, — There is no specific fever which presents the same remark-
able group of phenomena. The period of incubation is from six to ten days.
" Clinically the fever has a peculiarly irregular temperature curve, consisting
of intermittent waves or undulations of pyrexia, of a distinctly remittent char-
acter. These pyrexial waves or undulations last, as a rule, from one to three
weeks, with an apyrexial interval lasting for two or more days. In rare
cases the remissions may become so marked as to give an almost intermittent
character to the febrile curve, clearly distinguishable, however, from the par-
oxysms of p'aludic infection. This pyrexial condition is usually much pro-
longed, having an uncertain duration, lasting for even six months or more.
ITnlike paludism, its course is not markedly affected by the administration of
quinine. Its course is often irregular and even erratic in nature. This pyrexia
is usually accompanied by obstinate constipation, progressive anaemia, and
debility. It is often complicated with and folloAved by neuralgic symptoms
referred to the peripheral or central nervous system, arthritic effusions, painful
inflammatory conditions of certain fibrous structures, of a localized nature, or
swelling of the testicles " (Hughes) . This author recognizes a malignant type,
in which the disease may prove fatal within a week or ten days; an undula-
tory type — the common variety — in which the fever is marked by intermittent
waves or undulations of variable length, separated l)y periods of apyrexia and
freedom from symptoms. In this really lie the peculiar features of the disease,
and the unfortunate victim may suffer a series of relapses which may extend
from three months, the average time, to two years. Lastly, there is an inter-
mittent type, in which the patient may simply have daily pyrexia toward even-
ing, without any special complications, and may do well and be able to go
about his work, and yet at any time the other serious features of the disease
may develop.
BERI-BERL 249
The mortality is slight, only ahout 2 per cent. There are no characteristic
morbid lesions. Malta fever can now be readily differentiated from enteric
fever and malaria. The prophylaxis is self-evident, and the brilliant work
of the commission has already reduced the incidence of the disease to a
minimum.
Treatment. — General measures suitable to typhoid fever are indicated.
Fluid food should be given during the febrile period. Hydrotherapy, either
the bath or the cold pack, should be used every third hour when the tempera-
ture is above 103° F. Otherwise the treatment is symptomatic. No drugs
appear to have any special influence on the fever. A change of climate seems
to promote convalescence.
XXV. BERI-BERI.
Definition. — An endemic and epidemic multiple neuritis of unknown etiol-
ogy, occurring in tropical and subtropical countries, characterized by motor
and sensory paralysis and anasarca.
History. — The disease is believed to be of great antiquity in China, and
is possibly mentioned -in the oldest known medical treatise. In the early years
of the nineteenth century it attracted much attention among the Anglo-Indian
surgeons, and we may date the modern scientific study of the disease from
Malcolmson's monograph, published in Madras in 1835. The opening of
Japan gave an opportunity to the European physicians holding university posi-
tions, particularly Anderson, Baelz, Scheube, and more recently Grimm, to
investigate the disease. The studies of the native Japanese physicians, particu-
larly Miura and Takagi, and of the Dutch physicians in the East, have con-
tributed much to our knowledge. An added interest has been given to the
subject by the discovery of the disease among the Cape Cod fishermen, and by
the recurring outbreaks of endemic neuritis at the Richmond Asylum in Dub-
lin and at the State Insane Hospital at Tuscaloosa, Ala.
Distribution. — Beri-beri, Kakke, or endemic neuritis prevails most exten-
sively in the Malay Archipelago ; in certain of the Dutch colonies the mortality
among the coolies is simply frightful. It is widely distributed in China,
Japan, and the Philippine Islands. In the Philippines the admissions to the
Government hospitals for the year ending June 30, 1903, were Q>2:&, nearly
all among the Philippine scouts. In India it has become less common, but
is still prevalent in parts of Burma. Localized outbreaks have occurred in
Australia. It prevails extensively in parts of South America and in the West
Indies, and from the ports of these countries cases occasionally reach the
United States, and it occurs also among the Chinese and Japanese in Califor-
nia. Birge, of Provincetown, and J. J. Putnam encountered beri-beri among
the fishermen on the Newfoundland Banks. Birge writes (March 10, 1898)
that he has seen 47 cases of both the wet and the dry form. The disease is not
entirely confined to the fishermen on the Grand Banks, but occurs occasionally
among those living on shore or making " shore trips." In 1895-'96 a remark-
able outbreak of epidemic neuritis occurred at the State Insane Hospital at
Tuscaloosa, Ala., which has been described fully by E. D. Bondurant. Be-
tween February, 1895, and October, 1896, in a population of 1,200 there were
71 cases with 21 deaths. None occurred among the 200 employees of the hos-
250 SPECIFIC INFECTIOUS DISEASES.
pital. The negroes were relatively less affected than the whites. The chief
symptoms were " muscular weakness, tenderness, pain, pargesthesis, loss of
deep reflexes, followed by atrophy of muscles and the electrical reaction of
degeneration, accompanied by rise of temperature, gastro-intestinal disturb-
ance, general anasarca, and tachycardia." At the Arkansas State Insane
Asylum at Little Eock, in 1895, there was an outbreak of between 20 and 30
cases possibly of beri-beri.
In Great Britain the disease is not infrequent at the seaports.
At the Eichmond Asylum, Dublin, there have been extensive outbreaks
in the years 1894, 1896, 1897, under conditions of overcrowding.
Etiology. — Two main views prevail as to the nature of the disease — that
it is an infection, and that it is a toxaemia caused by food.
1. Beri-beri as an Acute Inpection. — Baelz and Scheube, with many of
the Dutch physicians, hold that the disease is due to a germ. In favor of this
view, Scheube refers to the fact that strong, well-nourished young people are
attacked, that the disease has definite foci in which it prevails, definite seasonal
relations, and has of late j^ears spread in some countries as an epidemic with-
out any special change in the diet of the inhabitants. So far as seasonal and
telluric influences are concerned, it is a disease which resembles malaria, with
which, in fact, some authors have confounded it. It is probably not directly
contagious. On the other hand, Scheube, Manson and others bring forward
evidence to show that beri-beri may probably be conveyed from one district to
another. Many bacteriological studies have been made in the disease, par-
ticularly by Dutch physicians, but there is no unanimity as to the results, and
we may say that no specific organism has as yet been determined upon.
Hamilton Wright, who has made a prolonged study of the disease in the
Malay States, describes a specific duodenitis, a primary bacterial lesion, from
which the poison is evolved. Just as it is from the throat in diphtheria.
2. Food Theory. — This theory is widely held in Japan, some believing
that it is due to the eating of bad rice, and others that it is associated with the
use of certain fish. In favor of the dietetic View of its origin is adduced the
extraordinary change which has taken place in the Japanese navy since the
introduction by Takagi of an improved diet, allowing a larger portion of
nitrogenous food, and forbidding the use of fresh fish altogether. Subsequent
to this there has certainly been the most remarkable diminution in the num-
ber of cases — a reduction from about a fourth of the entire strength attacked
annually to a practical abolition of the disease.
Many of the Dutch physicians in Java regard rice as the important cause
of the disease. It is stated that in the prisons of Java the proportion of cases
is 1 to 39 when the rice is eaten completely shelled, 1 to 10,000 when the grain
is eaten with its pericarp; in some places the disease has disappeared when
the unshelled rice has been substituted for the shelled. Miura, with whose
studies of the disease all readers of Yirchow's Archiv are familiar, regards
ben-beri as a form of chronic poisoning due to the use of the flesh of certain
fish eaten raw or improperly prepared. Grimm, in his monograph, regards
the immunity of Europeans as in great part owing to the fact that they do
not follow the Japanese custom of eating various kinds of raw fish.
_ Among the most important factors are the following : Overcrowding, as in
ships, jails, and asylums, hot and moist seasons, and exposure to wet. Euro-
BERI-BERI. 251
peans under good hygienic conditions rarely contract the disease in beri-beri
regions. The natives and the imported coolies are most often attacked. Males
are more subject to the disease than females. Young men from sixteen to
twenty-five are chiefly affected.
Symptoms. — The incubation period is unknown, but it probably extends
over several months. The following forms of the disease are recognized by
Scheube :
1. The incomplete or rudimentary form which often sets in with ca-
tarrhal symptoms, followed by pains and weakness in the limbs and a lower-
ing of the sensibility in the legs, with the occurrence of parsesthesiae. Slight
oedema sometimes appears. After a time parjEsthesige are felt in other parts
of the body, and the patient may complain of palpitation of the heart, uneasy
sensations in the abdomen, and sometimes shortness of breath. There may be
weakness and tenderness of the muscles. After lasting from a few days to
many months, these sjonptoms all disappear, but with the return of the warm
weather there may be a recurrence. One of Scheube's patients suffered in this
way for twenty years.
3. The atrophic form sets in with much the same symptoms, but the
loss of power in the limbs progresses more rapidly, and very soon the patient
is no longer able to walk or to move the arms. The atrophy, which is associ-
ated with a good deal of pain, may extend to the muscles of the face. T^he
cedematous symptoms and heart troubles play a minor role in this form, which
is known as the dry or paralytic variety.
3. The Wet or Dropsical Form. — Setting in as in the rudimentary vari-
ety, the oedema soon becomes the most marked feature, extending over the
whole subcutaneous tissue, and associated with effusions into the serous sacs.
The atrophy of the muscles and disturbance of sensation are not such promi-
nent symptoms. On the other hand, palpitation and rapid action of the heart
and dyspnoea are common. The wasting may not be apparent until the dropsy
disappears.
4. The acute, pernicious, or cardiac form is characterized by threat-
enings of an acute cardiac failure, coming on rapidly after the existence of
slight symptoms, such as occur in the rudimentary form. In the most acute
type death may follow within twenty-four hours; more commonly the symp-
toms extend over several weeks.
The mortality of the disease varies greatly, from 2 or 3 per cent to 40
or 50 per cent among the coolies in certain of the settlements of the Malay
Archipelago.
Morbid Anatomy. — The most constant and striking features are changes
in the peripheral nerves and degenerative inflammation involving the axis
cylinder and medullary sheaths. In the acute cases this is found not only in
the peripheral nerves, but also in the pneumogastric and in the phrenic. The
fibres of the voluntary muscles, as well as of the myocardium, are also much
degenerated. Hamilton Wright has described an acute duodenitis.
Diagnosis. — In tropical countries there is rarely any difficulty in the
diagnosis. In cases of peripheral neuritis, associated with oedema, coming
from tropical ports, the possibility of this disease should be remembered.
Scheube states that rarely any difficulty offers in the diagnosis of the differ-
ent forms.
252 SPECIFIC INFECTIOUS DISEASES.
Treatment.— Much has been done to prevent the disease, particularly in
Japan There is no more remarkable triumph of modern hygiene than that
which followed Takagi's dietetic reforms in the Japanese navy. In beri-beri
districts Europeans should use a diet rich in nitrogenous ingredients. In the
dietary of prisons and asylums the experience of the Javanese physicians with
reference to the remarkable diminution of the disease with the use of unshelled
rice should be borne in mind. In ships, prisons, and asylums the disease has
rarely occurred except in connection with overcrowding, an element which pre-
vailed both at the Eichmond Asylum and at the State Hospital for the Insane
at Tuscaloosa.
Baelz recommends in early cases a free use of the salicylates, 15 or 20
grains four or five times a day. Others favor early free purgation. In very
severe acute cases, both Anderson and Baelz advise blood-letting. The more
chronic cases demand, in addition to dietetic measures, drugs to support the
heart and treatment of the atrophied muscles with electricity and massage.
XXVI. ANTHRAX.
(Splenic Fever; Charbon; Wool-sorter's Disease.)
Definition. — An acute infectious disease caused by Bacillus anthracis. It
is a wide-spread affection in animals, particularly in sheep and cattle. In
man it occurs sporadically or as a result of accidental inoculations with the
virus.
Etiology. — The infectious agent is a non-motile, rod-shaped organism. Ba-
cillus anthracis, which has, by the researches of Pollender, Davaine, Koch,
and Pasteur, become the best known perhaps of all pathogenic microbes. The
bacillus has a length of from 2 to 25 /a; the rods are often united. The bacilli
themselves are readily destroyed, but the spores are very resistant, and sur-
vive after prolonged immersion in a 5-per-cent solution of carbolic acid, or
withstand for some minutes a temperature of 212° Fahr. They are capable
also of resisting gastric digestion. Outside the body the spores are in all prob-
ability very durable.
In Animals. — Geographically and zoologically the disease is the most
widespread of all infectious disorders. It is much more prevalent in Europe
and in Asia than in America. Its ravages among the herds of cattle in Russia
and Siberia, and among sheep in certain parts of Europe, are not equalled
by any other animal plague. In the United States anthrax is not very wide-
spread. Mohler, of the Bureau of Animal Industry, informs me that since
1900 it has been reported in cattle from sixteen States. It is not very uncom-
mon in Delaware, New Jersey, and Penns5dvania.
A protective inoculation- with a mitigated virus was introduced by Pasteur,
and has been adopted in certain anthrax regions. Mendez describes excellent
results from his antitoxin (1904).
The disease is conveyed sometimes by direct inoculation, as by the bites
and stings of insects, by feeding on carcasses of animals which have died of
the disease, but more commonly by grazing in pastures in which the germs
have been preserved. Pasteur believes that the earthworm plays an impor-
tant part in bringing to the surface and distributing the bacilli which have
ANTHRAX. 253
been propagated in the buried carcass of an infected animal. Certain jfields,
or even farms, may thus be infected for an indefinite period of time. It seems
probable, however, that if the carcass is not opened or the blood spilt, spores
are not formed in the buried animal and the bacilli quickly die.
In man the disease does not occur spontaneously. It results always from
infection, either through the skin or intestines, or in rare instances through
the lungs. Workers in wool and hair, and persons whose occupations bring
them into contact with animals or animal products, as stablemen, shepherds,
tanners, and butchers, are specially liable to the disease. In Pennsylvania in
1897 twelve tanners died of anthrax. It is rare in general hospital work.
There has been only one case in sixteen years at the Johns Hopkins Hospital.
In England and Wales in 1903 there Avere 17 deaths from this cause in man
(Tatham). For the six years 1899-1904 there were 261 cases of industrial
anthrax reported to the Home Office; 25.6 per cent proved fatal (Legge).
Various forms of the disease have been described, and two chief groups
may be recognized: the external anthrax and the internal anthrax, of which
there are pulmonary and intestinal forms.
Symptoms. — (1) External Anthrax.
(a) Malignant Pustule. — The inoculation is usually on an exposed surface
— the hands, arms, or face. At the site of inoculation there are, within a few
hours, itching and uneasiness, and the gradual formation of a small papule,
which soon becomes vesicular. Inflammatory induration extends around this,
and within thirty-six hours, at the site of inoculation there is a dark brownish
eschar, at a little distance from which there may be a series of small vesicles.
The brawny induration may be extreme. The oedema produces very great
swelling of the parts. The inflammation extends along the lymphatics, and
the neighboring lymph-glands are swollen and sore. The fever at first rises
rapidly, and the concomitant phenomena are marked. Subsequently the tem-
perature falls, and in many cases becomes subnormal. Death may take place
in from three to five days. In cases which recover the constitutional symptoms
are slighter, the eschar gradually sloughs out, and the wound heals. The cases
vary much in severity. In the mildest form there may be only slight swelling.
At the site of inoculation a papule is formed, which rapidly becomes vesicular
and dries into a scab, which separates in the course of a few days.
(&) Malignant Anthrax CEdema. — This form occurs in the eyelid, and
also in the head, hand, and arm, and is characterized by the absence of the
papule and vesicle forms, and by the most extensive oedema, which may follow
rather than precede the constitutional symptoms. The oedema reaches such a
grade of intensity that gangrene results, and may involve a considerable sur-
face. The constitutional sym_ptoms then become extremely grave, and the
cases invariably prove fatal.
The greatest fatality is seen in cases of inoculation about the head and
face, where the mortality, according to Nasarow, is 26 per cent; the least in
infection of the lower extremities, where it is 5 per cent.
In a case at the Johns Hopkins Hospital in 1895, in a hair-picker, there
was most extensive enteritis, peritonitis, and endocarditis, which last lesion
has been described by Eppinger.
A feature in both these forms of malignant pustule, to which many writers
refer, is the absence of feeling of distress or anxiety on the part of the patient.
254 SPECIFIC INFECTIOUS DISEASES.
whose mental condition may be perfectly clear. He may be without any appre-
hension, even though the condition be most critical.
The diagnosis in most instances is readily made from the character of the
lesion and the occupation of the patient. When in doubt, the examination
of the fluid from the pustule may show the presence of the anthrax bacilli.
Cultures should be made, or a mouse or guinea-pig inoculated from the local
lesion. It is to be remembered that the blood may not show the bacilli in
numbers until shortly before death.
(3) Internal Anthrax.
(a) Intestinal Form, Mycosis intestinalis. — In these cases the infection
usually is through the stomach and intestines, and results from eating the
flesh or drinking the milk of diseased animals; it may, however, follow an
external infection if the germs are carried to the mouth. The symptoms are
those of intense poisoning. The disease may set in with a chill, followed by
vomiting, diarrhoea, moderate fever, and pains in the legs and back. In acute
cases there are dyspnoea, cyanosis, great anxiety and restlessness, and toward
the end convulsions or spasms of the muscles. Haemorrhage may occur from
the mucous membranes. Occasionally there are on the skin small phlegmonous
areas or petechiae. The spleen is enlarged. The blood is dark and remains
fluid for a long time after death. Late in the disease the bacilli may be found
in the blood.
This is one of the forms of acute poisoning which may affect many indi-
viduals together. Thus Butler and Karl Huber describe an epidemic in which
twenty-five persons were attacked after eating the flesh of an animal which
had had anthrax. Six died in from forty-eight hours to seven days.
(h) Wool-soi-ters Disease. — This important form of anthrax is found in
the large establishments in which wool or hair is sorted and cleansed. The
hair and wool imported into Europe from Eussia and South America appear
to have induced the largest number of cases. Many of these show no external
lesion. The infective material has been swallowed or inhaled with the
dust. There are rarely premonitory symptoms. The patient is seized with
a chill, becomes faint and prostrated, has pains in the back and legs, and the
temperature rises to 102° or 103°. The breathing is rapid, and he complains
of much pain in the chest. There may be a cough and signs of bronchitis.
So prominent in some instances are these bronchial s3rmptoms that a pulmo-
nary form of the disease has been described. The pulse is feeble and very
rapid. There may be vomiting, and death may occur within twenty-four hours
with symptoms of profound collapse and prostration. Other cases are more
protracted, and there may be diarrhoea, delirium, and unconsciousness. The
cerebral s}Tnptoms may be most intense ; in at least four cases the brain seems
to have been chiefly affected, and its capillaries stuffed with bacilli (Merkel).
The recognition of wool-sorter's disease as a form of anthrax is due to J. H.
Bell, of Bradford, England.
In certain instances these profound constitutional symptoms of internal
anthrax are associated with the external lesions of malignant pustule.
The rag-picker's disease has been made the subject of an exhaustive study
by Eppinger (Die Hadernkrankheit, Jena, 1894), who has shown that it is
a local anthrax of the lungs and pleura, with general infection.
The prophylaxis is important, and should be carried out by a most rigid
HYDROPHOBIA. 255
disinfection of the hides, hair, and rags before they are placed in the hands
of the workmen.
Treatment. — In malignant pustule the site of inoculation should be de-
stroyed by the caustic or hot iron, and powdered bichloride of mercury may
be sprinkled over the exposed surface. The local development of the bacilli
about the site of inoculation may be prevented by the subcutaneous injections
of solutions of carbolic acid or bichloride of mercury. The injections should
be made at various points around the pustule, and may be repeated two or
three times a day. The internal treatment should be confined to the admin-
istration of stimulants and plenty of nutritious food.
In malignant forms, particularly the intestinal cases, little can be done.
Active purgatives may be given at the outset, so as to remove the infecting
material. Quinine in large doses has been recommended.
An antianthrax serum has been prepared by Sclavo, for which good results
are claimed. (Legge, Milroy Lectures, B. M. J., March 18, 1905.)
XXVII. HYDROPHOBIA.
(Lyssa; Kabies.)
Definition. — An acute disease of warm-blooded animals, dependent upon
a specific virus, and communicated by inoculation to man.
Etiology. — Eabies is very variously distributed. In Eussia it is common.
In North Germany it is relatively rare, owing to the wise provision that all
dogs must be muzzled. In France it is much more common. In England the
muzzling order has been followed by a complete disappearance of the disease.
There was no death from hydrophobia in 1903. In the decennium ending
with 1890 the deaths averaged 29 annually (Tatham). In the United States
the disease occurs more often than is generally supposed, as is shown by the
number of authentic cases collected by Salmon [Yearbook of the United States
Department of Agriculture, p. 210, 1901].
Dogs are especially liable to the disease. It also occurs in the wolf, the
cat, and the cow. Most animals are susceptible; and it is communicable by
inoculation to the rabbit, horse, or pig. The disease is propagated chiefly by
the dog, which seems specially susceptible. In the Western States the skunk
is said to be very liable to the disease. The nature of the poison is as yet
unknown. It is contained chiefly in the nervous system and is met with in
some of the secretions, particularly in the saliva. Bartarelli has shown that
the virus reaches the dog's salivary glands by way of the nerves and not
through the blood-vessels.
A variable time elapses between the introduction of the virus and the
appearance of the symptoms. Horsley states that this depends upon the fol-
lowing factors: " (a) Age. The incubation is shorter in children than in
adults. For obvious reasons the former are more frequently attacked.
(&) Part infected. The rapidity of onset of the symptoms is greatly deter-
mined by the part of the body which may happen to have been bitten. Wounds
'about the face and head are especially dangerous; next in order in degrees
of mortality come bites on the hands, then injuries on the other parts of the
body. TJiis relative order is, no doubt, greatly dependent upon the fact that
256 SPECIFIC INFECTIOUS DISEASES.
the face head and hands are usually naked, while the other parts are clothed;
it would also appear to depend somewhat upon the richness m nerves of the
part (c) The extent and severity of the wound. Puncture wounds are the
most dangerous; the lacerations "are fatal in proportion to the extent of
the.surface afforded for absorption of the virus, (d) The animal conveymg the
infection In order of decreasing severity come : first, the wolf ; second, the
cat ; third, the dog ; and fourth, other animals." Ouly a limited number of
those bitten by rabid dogs become affected by the disease; according to Hors-
ley not more than 15 per cent. On the other hand, the death-rate of those
persons bitten by wolves is higher, not less than 40 per cent. Babes gives the
mortality as from CO to 80 per cent.
The incubation period in man is extremely variable. The average is from
six weeks to two months. In a few cases it has been under two weeks. It
may be prolonged to three months. It is stated that the incubation may be
prolonged for a year or even two years, but this has not been definitely settled.
Morbid Anatomy. — The important lesions consist in the accumulation of
leucocytes around the blood-vessels and the nerve-cells, particularly the motor
ganglion cells, of the central nervous system (rabic tubercles of Babes). Es-
pecial importance in the rapid diagnosis of rabies is attached by van Gehuch-
ten and jSTelis to the accumulation of lymphoid and endothelioid cells around
nerve-cells of the sympathetic and cerebro-spinal ganglia. Negri has described
in the central nervous system irregular bodies varying from 4 to 10 microns in
size, widespread, frequently in the cells of the cerebellum, cerebral cortex and
pons, and in the spinal cord. They are probably protozoa, and it is stated that
they furnish a rapid and trustworthy means of diagnosis. The inoculation
experiments show that the virus is not present in the liver, spleen, or kidneys,
but is abundant in the spinal cord, brain, and peripheral nerves.
Symptoms. — Three stages of the disease are recognized:
( 1 ) Premonitoet stage, in which there may be irritation about the bite,
pain, or numbness. The patient is depressed and melancholy; and complains
of headache and loss of appetite. He is very irritable and sleepless, and has
a constant sense of impending danger. There is often greatly increased sensi-
bility. A bright light or a loud voice is distressing. The larynx may be
injected and the first symptoms of difficulty in swallowing are experienced.
The voice also becomes husky. There is a slight rise in the temperature and
the pulse.
(2) Stage of Excitement. — This is characterized by great excitability
and restlessness, and an extreme degree of hypersesthesia. " Any afferent
stimulant — i. e., a sound or a draught of air, or the mere association of a
verljal suggestion — will cause a violent reflex spasm. In man this symptom
constitutes the most distressing feature of the malady. The spasms, which
affect particularly the muscles of the larynx and mouth, are exceedingly pain-
ful and are accompanied by an intense sense of dyspnoea, even when the glottis
is widely opened or tracheotomy has been performed" (Horsley). Any
attempt to take water is followed by an intensely painful spasm of the mus-
cles of the larynx and of the elevators of the hyoid bone. It is this which
makes the patient dread the very sight of water and gives the name hydro-
phobia to the disease. These spasmodic attacks may be associated with mania-
cal symptoms. In the intervals between the patient is quiet and the mind
HYDROPHOBIA. 257
unclouded. The temperature in this stage is usually elevated and may reach
from 100° to 103°. In some instances the disease is afebrile. The patient
rarely attempts to injure his attendants, and in the intense spasms may be
particularly anxious to avoid hurting any one. There are, however, occasional
fits of furious mania, and the patient may, in the contractions of the muscles
of the larynx and pharynx, give utterance to odd sounds. This stage lasts
from a day and a half to three days and gradually passes into the —
(3) Paralytic Stage. — In rodents the preliminary and furious stages
ar« absent, as a rule, and the paralytic stage may be marked from the outset
— the so-called dumb rabies. This stage rarely lasts longer than from six to
eighteen hours. The patient then becomes quiet ; the spasms no longer occur ;
unconsciousness gradually supervenes; the heart's action becomes more and
more enfeebled, and death occurs by syncope.
Diagnosis. — In man the diagnosis offers no special difficulties. It is advis-
able, in cases attended with any doubts, as soon as possible after the injury
has been inflicted, to secure the medulla oblongata of the supposed rabid ani-
mal for the purpose of inoculating rabbits. The subdural inoculation of rab-
bits with a small quantity of the central nervous system of a rabid animal
will be followed by the occurrence of the paralytic form of the disease in
from fifteen to twenty days.
Treatment. — Prophylaxis is of the greatest importance, and by a system-
atic muzzling of dogs the disease can be, as in parts of Germany, practically
eradicated.
The bites should be carefully washed and thoroughly cauterized with
caustic potash or concentrated carbolic acid. It is best to keep the wound
constantly open for at least five or six weeks. When once- established the
disease is hopelessly incurable. No measures have been found of the slightest
avail, consequently the treatment must be palliative. The patient should be
kept in a darkened room, in charge of not more than two attendants. To
allay the spasm, chloroform may be administered and morphia given hypo-
dermically. It is best to use these powerful remedies from the outset, and
not to temporize with chloral, bromide of potassium, and other less potent
drugs. By the local application of cocaine, the sensitiveness of the throat
may be diminished sufficiently to enable the patient to take liquid nourishment.
Sometimes he can swallow readily. Nutrient enemata should be administered.
Peeventive Inoculation. — Pasteur has found that the virus, when prop-
agated through a series of rabbits, increases in its virulence; so that whereas
subdural inoculation from the brain of a mad dog takes from fifteen to twenty
days to produce the disease, in successive inoculation in a series of rabbits
the incubation period is gradually reduced to seven days (virus fixe). The
spinal cords of these rabbits contain the virus in great intensity, but when
they are preserved in dry air this gradually diminishes. If now dogs are
inoculated from cords preserved for from twelve to fifteen days, and then
from cords preserved for a shorter period, i. e., with a progressively stronger
virus, they gradually acquire immunity against the disease. A dog treated
in this way will resist inoculation with the virus fixe, which otherwise would
inevitably have proved fatal. Eelying upon these experiments, Pasteur began
inoculations in the human subject, using, on successive days, material from
cords in which the virus was of varying degrees of intensity.
18
258 SPECIFIC INFECTIOUS DISEASES.
In 1902 there were 1,103 persons treated at the Paris Pasteur Institute,
with 2 deaths; in 1903 there were 630 persons treated, with 4 deaths, a
smaller number of cases than ever before treated, among them 10 foreigners,
one from Great Britain.
Pseudo-hydrophobia (Lyssophobia) . — This is a very interesting affection,
which may closely resemble hydrophobia, but is really nothing more than a
neurotic or hysterical manifestation. A nervous person bitten by a dog, either
rabid or supposed to be rabid, has within a few months, or even later, symp-
toms somewhat resembling the true disease. He is irritable and depressed.
He constantly declares his condition to be serious and that he will inevitably
become mad. He may have paroxysms in which he says he is unable to drink,
grasps at his throat, and becomes emotional. The temperature is not elevated
and the disease does not progress. It lasts much longer than the true rabies,
and is amenable to treatment. It is not improbable that a majority of the
cases of alleged recovery in this disease have been of this hysterical form. In
a ease which Burr reported from my clinic a few 5'ears ago the patient had
paroxysmal attacks in which he could not swallow. He was greatly excited
and alarmed at the sight of water and was extremely emotional. The symptoms
lasted for a couple of weeks and yielded to treatment with powerful electrical
currents.
XXVIII. TETANUS.
(Lockjaw.)
Definition. — An infectious malady characterized by tonic spasms of the
muscles with marked exacerbations. The virus is produced by a bacillus which
occurs in earth, in putrefying fluids, and manure, and is a normal inhabitant
of the intestines of many ruminants.
Etiolo^. — It occurs as an idiopathic affection or follows trauma. It is
frequent in some localities and has prevailed extensively in epidemic form
among new-born children, when it is kno"\va as tetanus or trismus neonatorum.
It is more common in hot than in temperate climates, and in the colored than
in the Caucasian race. This is particularly the case with tetanus following
confinement and in tetanus neonatorum. In certain of the West Indian
Islands more than one-half of the mortality among the negro children has
been due to this cause. St. Kilda, one of the western Hebrides, had been
scourged for years by the " eight days' sickness " among the new-bom. Of 125
children, 84 died within fourteen days of birth. Since the discovery of the
bacillus and the introduction of proper methods of treating the cord 27 chil-
dren have been born, of whom only one died of the disease (G. IS^. Turner,
1908) , which has now practically disappeared. In 4 majority of the cases there
is an injury which may be of the most trifling character. It is more common
after punctured and contused than after incised wounds, and frequently fol-
lows those of the hands and feet. The sjTnptoms usually appear within two
weeks of the injury. In some militarj^ campaigns tetanus has prevailed exten-
sively, but in others, as in the Civil War, the cases have been comparatively
few. ^ The tetanus bacillus has contaminated vaccines, and its presence in com-
mercial gelatine is a grave danger. Owing to the careless preparation of
the virus many cases of tetanus occurred in the neighborhood of Philadelphia
in 1901 among vaccinated children. In 1902 nineteen persons who had been
TETANUS. 259
inoculated against the plague in the village of Mulkowal died of tetanus.
In 1904 a remarkable outbreak occurred in a general hospital in the United
States in which 10 cases died after surgical operation. In all probability the
catgut (which is made from sheep's bowels) was at fault. The disease has
occurred after prolonged use of the hypodermic needle to inject morphia or
quinine; and it has followed the use of gelatine as a haemostatic.
The infectious nature of tetanus was suggested by its endemic occurrence
and from the manner of its behavior in certain institutions. Veterinarians
have long been of this belief, as cases are apt to occur together in horses in
one stable. On the eastern end of Long Island, where formerly the disease
was very prevalent, it is now rarely seen. An extraordinary number of cases
of tetanus have occurred in the United States as a result of injuries from the
toy pistols during the 4th of July celebration. The Journal of the American
Medical Association collected 415 cases in 1903, and began a propaganda
against the pistol, with the result that the fatalities have been reduced to 73
in 1907 and 76 in 1908 ! There has been a remarkable increase in the number
of deaths from the disease in England and Wales of late: 348 in 1905, 177 in
1903, 151 in 1903, 44 in 1901 (Tatham).
The Tetanus Bacillus. — The observations of Eosenbach, ISTicolaier, and
Kitasato have demonstrated that there is in connection with the disease a
specific organism which can be isolated and cultivated. Bacillus tetani is a
slender rod, which may grow into long threads. One end is often swollen and
occupied by a spore. It is motile, grows at ordinary temperatures, and is
anaerobic. The bacilli grow at the site of the wound (and do not invade the
blood and organs), where alone the toxin is manufactured, and it travels
upward along the nerves (Meyer). The antitoxin passes along the blood
stream (Wassermann). With small quantities of the culture the disease may
be transmitted to animals, which die with symptoms of tetanus. The poison
is a tox-albumin of extraordinary potency, which has been separated by Brieger
and Cohn in a state of tolerable purity. It is perhaps the most virulent poison
known. Whereas the fatal dose of strychnine for a man weighing 70 kilos is
from 30 to 100 milligrammes, that of the tetanus toxin is estimated at 0.33
milligramme. Every feature of the disease can be produced by it experimen-
tally without the presence of the bacilli. The symptoms do not arise imme-
diately, as in the case of ordinary poisons, but slowly, and it has been suggested
that it acts only after undergoing some further change in the body. The
natural home of the tetanus bacillus is the soil and the intestinal canal of
herbivorous animals. The disease can be produced by inoculating animals
with garden earth. A high degree of antitoxic immunity can be conferred on
animals, which then yield a protective serum. It is, however, difficult to cure
animals with this serum on account of the combination of the toxin with nerve-
cells by the time symptoms appear.
Morbid Anatomy. — 'Ho characteristic lesions have been found in the cord
or in the brain. Congestions occur in diiferent parts, and perivascular exu-
dations and granular changes in the nerve-cells have been found. The
condition of the wound is variable. The nerves are often found injured, red-
dened, and swollen. In the tetanus neonatorum the umbilicus may be inflamed.
Symptoms. — After an injury the disease sets in usually within ten days.
In Yandell's statistics in at least two-fifths, and in Joseph Jones's in four-
260 SPECIFIC INFECTIOUS DISEASES.
fifths, the symptoms occurred before the fifteenth day. The patient complains
at first of slight stiffness in the neck, or a feeling of tightness in the jaws,
or difficulty in mastication. Occasionally chilly feelings or actual rigors may
precede these symptoms. Gradually a tonic spasm of the muscles of these
parts produces the condition of trismus or lockjaw. The eyebrows may be
raised and the angles of the mouth drawn out, causing the so-called sardonic
grin — risus sardonicus. In children the spasm may be confined to these parts.
Sometimes the attack is associated with paralysis of the facial muscles and
difficulty in swallowing — the head-tetanus of Eose, which has most commonly
followed injuries in the neighborhood of the fifth nerve. Gradually the pro-
cess extends and involves the muscles of the body. Those of the back are
most affected, so that during the spasm the unfortunate victim may rest upon
the head and heels — a position known as opisthotonos. The rectus abdom-
inis muscle has been torn across in the spasm. The entire trunk and limbs
may be perfectly rigid — orthotonos. Flexion to one side is less common —
pleurothotonos ; while spasm of the muscles of the abdomen may cause the
body to be bent forward — emprosthotonos. In very violent attacks the thorax
is compressed, the respirations are rapid, and spasm of the glottis may occur,
causing asphyxia. The paroxysms last for a variable period, but even in the
intervals the relaxation is not complete. The slightest irritation is sufficient
to cause a spasm. The paroxysms are associated with agonizing pain, and the
patient may be held as in a vise, unable to utter a word. Usually he is bathed
in a profuse sweat. The temperature may remain normal throughout, or show
only a slight elevation toward the close. In other cases the pyrexia is marked
from the outset; the temperature reaches 105° or 106°, and before death 109°
or 110°. In rare instances it may go still higher. Death either occurs during
the paroxysm from heart-failure or asphyxia, or is due to exhaustion.
The cephalic tetanus {Kopftetanus of Eose) originates usually from a
wound on one side of the head, and is characterized by stiffness of the muscles
of the jaw and paralysis of the facial muscles on the same side as the wound,
with difficulty in swallowing. The prognosis is good in the chronic cases;
of those in Willard's table only 8 of 32 died; but in the acute form, of 45
cases, only 4 recovered.
Diagnosis. — Well-marked cases following a trauma could not be mis-
taken for any other disease. The spasms are not unlike those of strychnia-
poisoning, and in the celebrated Palmer murder trial this was the plea for
the defence. The jaw-muscles, however, are never involved early, if at all,
and between the paroxysms in strychnia-poisoning there is no rigidity. In
tetany the distribution of the spasm at the extremities, the peculiar position,
the greater involvement of the hands, and the condition under which it occurs,
are sufficient to make the diagnosis clear. In doubtful cases cultures should
be made from the pus of the wound.
Escherich has described in children a form of generalized tonic contrac-
tures of the muscles of the jaw, neck, back, and limbs, usually a sequel of
some acute infection, occasionally occurring as an independent malady. The
contractures may be either intermittent or persistent. The condition may last
from a week to a couple of months. The eases as a rule recover.
Prognosis. — Two of the Hippocratic aphorisms express tersely the general
prognosis even at the present day : " The spasm supervening on a wound is
GLANDERS. " 261
fatal," and "such persons as are seized with tetanus die within four days,
or if they pass these they recover."
The mortality in the traumatic cases is not less than 80 per cent (Con-
ner) ; in the idiopathic cases it is under 50 per cent. According to Yandell,
the mortality is greatest in children. Favorable indications are: late onset
of the attack, localization of the spasms to the muscles of the neck and jaw,
and an absence of fever.
Treatment. — Local treatment of -the wound is essential, as the poison is
manufactured here. Tizzoni advises nitrate of silver as the best germicide
for the tetanus bacillus. Thorough excision and antiseptic treatment should
be carried out, and the serum applied locally. It should also be used as a
prophylactic in suspicious wounds of gardeners and stable men. The patient
should be kept in a darkened room, absolutely quiet, and attended by only one
person. All possible sources of irritation should be avoided. Veterinarians
appreciate the importance of this complete seclusion in treating horses.
When the lockjaw is extreme the patient may not be able to take food by
the mouth, under which circumstances it is best to use rectal injections, or
to feed by a catheter passed through the nose. The spasm should be controlled
by chloroform, which may be repeatedly exhibited at intervals. It is more
satisfactory to keep the patient thoroughly under the influence of morphia
given hypodermically. Chloral hydrate, bromide of potassium. Calabar bean,
curara, Indian hemp, belladonna, and other drugs have been recommended,
and recovery occasionally follows their use. Resection of the nerve and
amputation of the limb have been advised. Although tetanus antitoxin of
great strength can be obtained, its use in the treatment of human tetanus
has been disappointing. The best results are obtained in the subacute cases,
but here the prognosis is relatively favorable even with other methods of
treatment. There may be occasion for the prophylactic use of the antitoxin
in man, as already successfully practised in arresting the spread of the disease
in horses occupying infected stables. Of the antitoxic serum 20 to 30 cc. may
be used for the first dose and 15 to 20 cc. every five or ten hours after. Tiz-
zoni advises 2.25 grammes of his antitoxin for the first dose and 0.6 grammes
for subsequent doses,
XXIX. GLANDERS (Farcy).
Definition. — An infectious disease of the horse, caused by Bacillus mal-
lei, communicated occasionally to man. In the horse it is characterized by the
formation of nodules, chiefly in the nares (glanders), and beneath the skin
(farcy).
Etiology. — The disease belongs to the infective granulomata. The local
manifestations in the nostrils and the skin of the horse are due to one and
the same cause. The specific germ was discovered by Loeffler and Schutz.
It is a short, non-motile bacillus, not unlike that of tubercle, but exhibits dif-
ferent staining reactions. It grows readily on the ordinary culture media.
For the full recognition of glanders in man we are indebted to the labors of
Eayer, whose monograph remains one of the best descriptions ever given of
the disease. Man becomes infected by contact with diseased animals, and
usually by inoculation on an abraded surface of the skin. The contagion may
262 SPECIFIC INFECTIOUS DISEASES.
also be received on the mucous membrane. In a Montreal case a gentleman
was probably infected by the material expelled from the nostril of his horse,
which was not suspected of having the disease. It is a rare disease. Only 6
deaths were registered from this cause in England and Wales in 1903. Among
laboratory workers the Bacillus mallei has caused more deaths than any other
germ, and in working with it the greatest possible precautions should be taken.
Morbid Anatomy. — As in the horse, the disease may be localized in the
nose (glanders) or beneath the sldn (f'arcy). The essential lesion is the
granulomatous tumor, characterized by the presence of numerous lymphoid
and epithelioid cells, among and in which are seen the glanders bacilli. These
nodular masses tend to break do^vn rapidly, and on the mucous membrane
result in ulcers, while beneath the skin they form abscesses. The glanders nod-
ules may also occur in the internal organs.
Symptoms. — An acute and a chronic form of glanders may be recognized
in man, and an acute and a chronic form of ioxcj.
Acute Glaxders. — The period of incubation is rarely more than three or
four days. There are signs of general febrile disturbance. At the site of
infection there are swelling, redness, and hinphangitis. Within two or three
days there is involvement of the mucous membrane of the nose, the nodules
break down rapidly to ulcers, and there is a muco-purulent discharge. An
eruption of papules, which rapidly become pustules, breaks out over the face
and about the joints. It has been mistaken for variola. In a Montreal case
this copious eruption led the attending physician to suspect small-pox, and
the patient was isolated. There is great swelling of the nose. The ulceration
may go on to necrosis, in which case the discharge is very offensive. The
hinph-glands of the neck are usually much enlarged. Subacute pneumonia is
very apt to occur. This form runs its course in about eight or ten da3'S, and
is invariably fatal. Glanders pneumonia ma}" appear after subcutaneous infec-
tion (one case from infection with hj-podermic s3Tinge stuck into thumb).
Grossly the lung appeared like a caseous pneumonia.
Chronic glaxders is rare and difficult to diagnose, as it is usually mis-
taken for a chronic cor3'za. There are ulcers in the nose, and often laryn-
geal symptoms. It may last for months, or even longer, and recovery some-
times takes place. Tedeschi has described a case of chronic osteomj^elitis, due
to the bacillus mallei, which was followed by a fatal glanders meningitis.
The diagnosis may be extremely difficult. In such cases a suspension of the
secretion, or of cultures upon agar-agar made from the secretion, should be
injected into the peritoneal cavity of a male guinea-pig. At the end of two
days, in positive cases, the testicles are found to be swollen and the skin of
the scrotum reddened. The testicles continue to increase in size, and finally
suppurate. Death takes place after the lapse of two or three weeks, and gen-
eralized glanders nodules are found in the viscera. The use of mallein for
diagnostic purposes is highly recommended. The principles and methods of
application are the same as for tuberculin. McFadyean and others have shown
that while the glanders bacilli are agglutinated in a dilution of 1 to 200 by
normal horse serum, that of a glanders horse will agglutinate at 1 to 1,000.
The test must be made before maUein is given.
Acute farcy in man results usually from the inoculation of the virus into
the skin. There is an intense local reaction with a phlegmonous inflamma-
ACTINOMYCOSIS. 263
tion. The lymphatics are early affected, and along their course there are nod-
ular subcutaneous enlargements, the so-called farcy buds, which may rapidly
go on to suppuration. There are pains and swelling in the joints, and abscesses
may form in the muscles. The symptoms are those of an acute infection,
almost like an acute septicaemia. The nose is not involved and the superficial
skin eruption is not common. The bacilli have been found in the urine in
acute cases in man and animals.
The disease is fatal in a large proportion of the cases, usually in from
twelve to fifteen days.
Cheonic farcy is characterized by the presence of localized tumors, usu-
ally in the extremities. These tumors break down into abscesses, and some-
times form deep ulcers, without much inflammatory reaction and without
special involvement of the lymphatics. The disease may last for months or
even years. Death may result from pyaemia, or occasionally acute glanders
develops. The celebrated French veterinarian Bouley had it and recovered.
The disease is transmissible also from man to man. Washerwomen have
been infected from the clothes of a patient. In the diagnosis of this affec-
tion the occupation is very important. ISTowadays, in cases of doubt the inocu-
lation should be made in animals, as in this way the disease can be readily
determined. Mallein, a product of the growth of the bacilli, is now used for
the purpose of diagnosing glanders in animals. Several instances of cured
glanders have been reported in animals treated with small and repeated doses
of mallein (Pilavios, Babes).
Treatment. — If seen early, the wound should be either cut out or thor-
oughly destroyed by caustics and an antiseptic dressing applied. The farcy
buds should be early opened. In the acute cases there is very little hope. In
the chronic cases recovery is possible, though often tedious.
XXX. ACTINOMYCOSIS.
Definition. — A chronic infective disorder produced by the actinomyces or
ray-fungus, Streptothrix actinomyces.
Etiology. — The disease is widespread among cattle, and occurs also in the
pig. It was first described by Bollinger in the ox, in which it forms the affec-
tion known in this country as " big-jaw." The first accurate description
of the disease in man was given by James Israel, and subsequently Ponfick
insisted upon the identity of the disease in man and cattle.
In the United States and England the disease is less common than in Ger-
many. In 1902 Erving collected 100 cases in America. It is nearly three
times as common in men as in women.
The parasite belongs probably to the StreptotJirix group of bacteria. In
both man and cattle it can be seen in the pus from the affected region as yel-
lowish or opaque granules from one-half to two millimetres in diameter, which
are made up of cocci and radiating threads, which present bulbous, club-like
terminations. The youngest granules are gray in color and semi-translucent;
in these the bulbous extremities are wanting.
The parasite has been successfully cultivated, and the disease has been
inoculated both with the natural and artificially grown organism.
264 SPECIFIC INFECTIOUS DISEASES.
The Mode .of Infection.— There is no evidence of direct infection with the
flesh or milk of diseased animals. The streptothrix has not been detected out-
side the body. It seems highly probable that it is taken in with the food. The
site of infection in a majority of cases in man and animals is in the mouth
or neighboring passages. In the cow, possibly also in man, barley, oats, and
rye have been carriers of the germ.
Morbid Anatomy.— As in tubercle, the first effect is the destruction of
adjacent cells and the attraction of leucocytes— later the surrounding cells
begin to proliferate. After the tumor reaches a certain size there is great
proliferation of the surrounding connective tissue, and the growth may, par-
ticularly in the jaw, look like, and was long mistaken for, osteo-sarcoma.
Finally suppuration occurs, which in man, according to Israel, may be pro-
duced directly by the streptothrix itself.
Clinical Forms. — (a) Digestive Tract. — Israel is said to have found
the fungus in the cavities of carious teeth. The jaw has been affected in a
number of cases in man. The patient comes under observation with swelling
of one side of the face, or with a chronic enlargement of the jaw which may
simulate sarcoma.
The tongue has been involved in several cases, showing small growths,
either primary or following disease of the jaw. In the intestines the dis-
ease may occur either as a primary or secondary affection. Cases have been
reported of pericgecal abscess due to the germ. An actinomycotic appendi-
citis has been described; primary actinomycosis of the large intestine with
metastases has also been found. Eansom has found the actinomyces in the
stools. Actinomycotic peritonitis due to infection through a gastrostomy
wound has been described. Actinomycosis of the liver is rare. Auvray in
1903 could only collect 31 cases (Eolleston). It forms a most characteristic
lesion — an alveolar honey-combed abscess — like a sponge soaked in pus. It
is usually secondary to an intestinal lesion, but in a few cases no other focus
has been found,
(h) Pulmonary Actinomycosis. — In September, 1878, James Israel de-
scribed a remarkable mycotic disease of the lungs, which subsequent observa-
tion showed to be the affection described the year before by Bollinger in cattle.
Since that date many instances have been reported in which the lungs were
affected. It is a chronic infectious pulmonary disorder, characterized by
cough, fever, wasting, and a muco-purulent, sometimes foetid, expectoration.
The lesions are unilateral in a majority of the cases. Hodenpyl classifies them
in three groups: (1) Lesions of chronic bronchitis; the diagnosis has been
made by the presence of the actinomyces in the sputum. (2) Miliary actino-
mycosis, closely resembling miliary tubercle, but the nodules are seen to be
made up of groups of fungi, surrounded by granulation tissue. This form of
pulmonary actinomycosis is not infrequent in oxen with advanced disease of
the jaw or adjacent structures. (3) The cases in which there is more exten-
sive destructive disease of the lungs, broncho-pneumonia, interstitial changes,
and abscesses, the latter forming cavities large enough to be diagnosed during
life. Actinomycotic lesions of other organs are often present in connection
with the pulmonary disease; erosion of the vertebrae, necrosis of the ribs and
sternum, with node-like formations, subcutaneous abscesses, and occasionally
metastases in all parts of the body.
SYPHILIS. 265
(c) Cutaneous Actinomycosis. — In several instances in connection with
chronic ulcerative diseases of the skin the ray-fungus has been found. It is
a very chronic affection resembling tuberculosis of the skin, associated with
the growth of tumors which suppurate and leave open sores, which may remain
for years.
(d) Cerebral Actinomycosis. — Bollinger has reported an instance of
primary disease of the brain. The symptoms were those of tumor. A second
remarkable case has been reported by Gamgee and Delepine. The patient was
admitted to St. George's Hospital with left-sided pleural effusion. At the
post mortem three pints of purulent fluid were found in the left pleura ; there
was an actinomycotic abscess of the liver, and in the brain there were abscesses
in the frontal, parietal, and temporo-sphenoidal lobes which contained the
mycelium, but no clubs. A third case, reported by 0. B. Keller, had empyema
necessitatis, which was opened and actinomycetes were found in the pus. Sub-
sequently she had Jacksonian epilepsy, for which she was trephined twice and
abscesses opened, which contained actinomyces grains. Death occurred after
the second operation.
Symptoms. — The fever is of an irregular type and depends largely on the
existence of suppuration. The cough is an important symptom, and the diag-
nosis in 18 of the cases was made during life by the discovery of the actino-
myces. Death results usually with septic symptoms. Occasionally there is a
condition simulating typhoid fever. The average duration of the disease was
ten months. Eecovery is very rare. Clinically the disease closely resembles
certain forms of pulmonary tuberculosis and of foetid bronchitis. It is not
to be forgotten in the examination of the sputum that, as Bizzozero mentions,
certain degenerated epithelial cells may be mistaken for the organism. The
radiating leptothrix threads about the epithelium of the mouth sometimes
present a striking resemblance.
Diagnosis. — The disease is in reality a chronic pyaemia. The only test is
the presence of the actinomyces in the pus. Metastases may occur as in pyae-
mia and in tumors. The tendency, however, is rather to the production of
a local purulent affection which erodes the bones and is very destructive.
Treatment. — This is largely surgical and is practically that of pyaemia.
Incision of the abscess, removal of the dead bone, and thorough irrigation
are appropriate measures. Thomassen has recommended iodide of potassium,
which, in doses of from 40 to 60 grains daily, has proved curative in a number
of recent cases.
XXXI. SYPHILIS.
Definition. — A specific disease of slow evolution, caused by the Spirochceta
pallida, propagated by inoculation (acquired syphilis) or by hereditary trans-
mission (congenital syphilis).
I. General Etiology and Morbid Anatomy.
Since the sixth edition of this work appeared there have been three remark-
able advances in our knowledge of syphilis — the discovery of the germ, the
transmission of the disease to apes, and the serum diagnosis of the disease.
19
266 SPECIFIC INFECTIOUS DISEASES.
The Spirochceta pallida, discovered by Schaudinn, a spirally curved organ-
ism from 10 to 15 /A in length, is found in primary, secondary and tertiary
lesions, and may be inoculated successfully into apes, monkeys, and rabbits. It
is believed to be a protozoan, but it has not yet been cultivated. In the con-
genital lesions it is present in extraordinary numbers.
Modes of Infection. — (1) In a large majority of all cases the disease is
transmitted by sexual congress, but the designation venereal disease {lues
venerea) is not always correct, as there are many other modes of inoculation.
In the St. Louis collection there are illustrations of 26 varieties of extra-
genital chancres.
(2) Accidental Infection. — In surgical and in midwifery practice physi-
cians are not infrequently inoculated. General infection may occur without
a characteristic local sore. Midwifery chancres are usually on the fingers,
but they may be on the back of the hand. The lip chancre is the most com-
mon of these erratic or extra-genital forms, and may be acquired in many ways
apart from direct infection. Mouth and tonsillar sores result as a rule from
improper practices. Wet-nurses are sometimes infected on the nipple, and it
occasionally happens that relatives of a syphilitic child are accidentally con-
taminated.
(3) Hereditary Transmission. — This is most common from (a) the father,
the mother being healthy (sperm inheritance). S. pallida has not yet been
found in the sperm cell, but we do not know its life phases, and from what we do
know of the history of syphilis, it seems probable that all the sperms cells are in-
fective. A syphilitic father may beget an apparently healthy child, even when
the disease is fresh and full-blown. On the other hand, in very rare instances, a
man may have had syphilis when young, undergo treatment, and for years
present no signs of disease, and yet his first-born may show very characteristic
lesions. The closer the begetting to the primary sore, the greater the chance
of infection. A man with tertiary lesions may beget healthy children. As a
general rule it may be said that with judicious treatment the transmissive
power rarely exceeds three or four years.
(&) Maternal transmission (germ inheritance). While the father may
not be affected, in a large number of instances both parents are diseased, the
one having infected the other, in which case the chances of foetal infection are
greatly increased. Heredity through the mother alone is much more fatal to
the offspring than paternal heredity. It is a remarkable and interesting fact
that a woman who has borne a syphilitic child is herself immune, and can not
be infected, though she may present no signs of the disease. This is known
as Beaumes' or Colles' law, and was thus stated by the distinguished Dublin
surgeon : " That a child born of a mother who is without obvious venereal
symptoms, and which, without being exposed to any infection subsequent
to its birth, shows this disease when a few weeks old, this child will infect the
most healthy nurse, whether she suckle it, or merely handle and dress it ; and
yet this child is never Imown to infect its own mother, even though she suckle
it while it has venereal ulcers of the lips and tongue." In a majority of these
cases the mother has received a sort of protective inoculation, without having
had actual manifestations of the disease. A child showing no taint, but born
of a woman suffering with syphilis may with impunity be suckled by its mother
(Prof eta's law).
SYPHILIS. 267
(:c) Placental transmission. The mother may be infected after concep-
tion, in which case the child may be, but is not necessarily, born syphilitic.
If the infection is late in pregnancy, after the seventh month, the child usually
escapes.
Morbid Anatomy.— The primary lesion, or chancre, shows: (a) A diffuse
infiltration of the connective tissue with small, round cells. (&) Larger epi-
thelioid cells, (c) Giant cells, (d) Changes in the small arteries and veins,
chiefly thickening of. the intima, and alterations in the nerve-fibres going to the
part. The sclerosis is due in part to this acute obliterative endarteritis. Asso-
ciated with the initial lesions are changes in the adjacent lymph-glands, which
undergo hyperplasia, and finally become indurated.
The secondary lesions of syphilis are too varied for description here. They
consist of condylomata, skin Eruptions, affections of the eye, etc.
The tertiary lesions consist of circumscribed tumors known as gummata,
various skin lesions, and a special type of arteritis.
Gummata. — Syphilomata occur in the bones or periosteum—here they are
called nodes — in the muscles, skin, brain, lung, liver, kidneys, heart, testes,
and adrenals. They vary in size from small, almost microscopic bodies to
large solid tumors from 3 to 5 cm. in diameter. They are usually firm and
hard, but in the skin and on the mucous membranes they tend to break down
rapidly and ulcerate. On cross-section a medium-sized gumma has a grayish-
white, homogeneous- appearance, presenting in the centre a firm, caseous sub-
stance, and at the periphery a translucent, fibrous tissue. Often there; are
groups of three or more surrounded by dense sclerotic tissue.
The arteritis will be considered in a separate section.
~ II. Acquired Syphilis.
Primary Stage. — This extends from the appearance of the initial sore until
the onset of the constitutional symptoms,. and has a variable duration of from
six to twelve weeks! The initial sore appears within a month after inocula-
tion, and it first shows itself as a small red papule, which gradually enlarges
and breaks in the centre, leaving a small ulcer. The tissue about this becomes
indurated so that it ultimately' has a gristly, cartilaginous consistence — ^hence
the name, hard or indurated chancre. The size attained is variable, and when
small the sore: may be overlooked, particularly if it is: just within the urethra.
The glands in the lymph-district of the chancre enlarge and become hard.
Suppuration both in the initiallesion and in the glands may occur as a sec-
ondary change. The_ general condition of the patient in this stage is good.
There may be no fever and no impairment of health. -
Secondary Stage,^ — The first constitutional symptoms. are usually mani-
.fested within three months of Ithe appearance of the primary sore. They
rarely occur earlier than the sixth or later than the twelfth week:
(a) ^ei;er, slight or. inten.se> and very variable in character, may occur
early before the skin rash'; more frequently it is the "fever of invasion" with
the secondary symptoms, or the fever may occur at any period. It may be a
mild continuous pyrexia, in other instances, with marked remissions, but the
most remarkable form is the intermittent, often mistaken for malaria. Such
cases have been reported by Yeo and by Sidney Phillips:. .The fever may reach
268 SPECIFIC INFECTIOUS DISEASES.
105° and the paroxysms persist for months. We have had several cases in
which typhoid fever was suspected (T. B. Futcher, Kew York Medical Jour-
nal, 1901), and in others tuberculosis.
(&) AncEmia.— In many cases the syphilitic poison causes a pronounced
anjemia which gives to the face a muddy pallor, and there may even be a
light-yellow tinging of the conjunctivae or of the skin, a hsematogenous
icterus. This syphilitic cachexia may in some instances be extreme. The red
blood-corpuscles do not show any special alterations. The blood-count may
fall to three millions per cubic millimetre, or even lower. The anaemia may
come on suddenly. In a case of s}T)hilitie arthritis in a young girl, following
three or four inunctions of mercury, the blood-count fell below two millions
per cubic millimetre in a few days.
(c) Cutaneous Lesions. — The earliest and most common is a macular
syphilide or syphilitic roseola, which occurs on the trunk, and on the front of
the arms. The face is often exempt. The spots, which are reddish-brown
and symmetrically arranged, persist for a week or two. There may be mul-
tiple relapses of roseola, sometimes at long intervals, even eleven years (Four-
nier). The papular sypliilide, which forms acne-like indurations about the
face and trunk, is often arranged in groups. Other forms are the pustular
rash, which may so closely simulate variola that the patient may be sent to
a small-pox hospital. A squamous syphilide occurs, not unlike ordinary psori-
asis, except that the scales are less abundant. The rash is more copper-colored
and not specially confined to the extensor surfaces.
In the moist regions of the skin, such as the perinaeum and groins, the
axillae, between the toes, and at the angles of the mouth, the so-called mucous
patches occur, which are flat, warty outgrowths, with well-defined margins and
surfaces covered with a grayish secretion. They are among the most distinc-
tive lesions of sj^hilis.
Frequently the hair falls out (alopecia), either in patches or by a general
thinning. Occasionally the nails become affected (syphilitic onychia).
(d) Mucous Lesions. — "With the fever and the roseolous rash the throat
and mouth become sore. The pharjTigeal mucosa is h3^peraemic, the tonsils
are swollen and often present small, kidney-shaped ulcers with grayish-white
borders. Mucous patches are seen on the inner surfaces of the cheeks and on
the tongue and lips. Hypertrophy of the papillae in various portions of the
mucous membrane produces the syphilitic warts or condylomata which are
most frequent about the vulva and anus.
(e) Arthritis and pains in the limbs are common secondary symptoms.
Occasionally the joint affection is severe and rheumatic fever is suspected.
(/) Other Lesions. — Iritis is common, and usually affects one eye before
the other. It comes on from three to six months after the chancre. There
may be only slight ciliary congestion in mild cases, but in severer forms there
is great pain, and the condition is serious and demands careful management.
Choroiditis and retinitis are rare secondary symptoms. Ear affections are not
common in the secondary stage, but instances are found in which sudden deaf-
ness occurs, which may be due to labyrinthine disease; more commonly the
impaired hearing is due to the extension of inflammation from the throat to
the middle ear. EpididjTnitis and parotitis are rare. Jaundice may occur, the
icterus syphiliticus precox. The acute nephritis will be referred to later.
SYPHILIS. 269
Tertiary Stage. — No hard and fast line can be drawn between the lesions
of the secondary and those of the tertiary period; and, indeed, in exceptional
cases, manifestations which usually appear late may set in even before the pri-
mary sore has properly healed. The special affections of this stage are certain
skin eruptions, gummatous growths in the viscera, and amyloid degenerations.
(a) The late syphilides show a greater tendency to ulceration and destruc-
tion of the deeper layers of the skin, so that in healing scars are left. They
are also more scattered and seldom symmetrical. One of the most character-
istic of the syphilides is rupia, the dry stratified crusts of which cover an ulcer
which involves the deeper layers of the skin and in healing leaves a scar.
It may be a secondary lesion.
(&) Gummata.— These may occur in the skin, subcutaneous tissue, mus-
cles, or internal organs. The general character has been already described.
In the skin they tend to break down and ulcerate, leaving ugly sores which
heal with difficulty. In the solid organs they undergo fibroid transformation
and produce puckering and deformity. On the mucous membranes these ter-
tiary lesions lead to ulceration, in the healing of which cicatrices are formed;
thus, in the larynx great narrowing may result, and in the rectum ulceration
with fibroid thickening and retraction may lead to stricture. Gummatous
ulcers may be infective.
(c) Amyloid Degeneration. — Syphilis plays a most important role in the
production of this affection. Of 344 instances analyzed by Fagge, 76 had
syphilis, and of these 42 had no bone lesions. It follows the acquired form and
is very common in association with rectal syphilis in women. In congenital
lues amyloid degeneration is rare.
Quaternary Stage. — Long years it may be from the primary sore and from
any active manifestations, certain diseases may follow, not directly syphilitic,
but dependent in some way upon its poison, and hence termed meta- or para-
syphilitic affections, the chief of which are locomotor ataxia and dementia
paralytica and aneurism.
III. Congenital Syphilis.
With the exception of the primary sore, every feature of the acquired dis-
ease may be seen in the congenital form.
The intra-uterine conditions leading to the death of the foetus do not here
concern us. The child may be born healthy-looking, or with well-marked evi-
dences of the disease. In the majority of instances the former is the case,
and within the first month or two the signs of the disease appear.
Symptoms. — (a) At Birth. — When the disease exists at birth the child
is feebly developed and wasted, and a skin eruption is usually present, com-
monly in the form of bullae about the hands and feet (pemphigus neonatorum
syphiliticus). The child snuffles, the lips are ulcerated, the angles of the
mouth fissured, and there is enlargement of the liver and spleen. The bone
symptoms may be marked, and the epiphyses may even be separated. In such
cases the children rarely survive long.
(&) Early Manifestations. — When born healthy the child thrives, is fat
and plump, and shows no abnormity whatever; then from the fourth to the
eighth week, rarely later, a nasal catarrh occurs, syphilitic rhinitis, which
impedes respiration, and produces the characteristic symptom which has given
270 SPECIFIC INFECTIOUS DISEASES.
the name snuffles to the disease. The discharge may be sero-punilent or
bloody. The child nurses with great difficulty. In severe cases ulceration
takes place with necrosis of the bone, leading to a depression at the root of
the nose and a deformity characteristic of congenital syphilis. This coryza
may be mistaken at first for an ordinary catarrh, but the coexistence of other
manifestations usually makes the diagnosis clear. The disease may extend
into the Eustachian tubes and middle ears and lead to deafness.
The cutaneous lesions arise mth or shortly after the onset of the snuf-
fles. The skin often has a sallow, earthy hue. The eruptions are first noticed
about the nates. There may be an erythema or an eczematous condition, but
more commonly there are irregular reddish-brown patches with well-defined
edges. A papular syphilide in this region is by no means uncommon. Fis-
sures occur al)out the lips, either at the angles of the mouth or in the median
line. These rliagades, as they are called, are very characteristic. There may
be marked ulceration of the muco-cutaneous surfaces. The secretions from
these mouth lesions are very virulent, and it is from this source that the wet-
nurse is usually infected. Not only the nurse, but members of the family, may
be contaminated. There are instances in which other children have been acci-
dentally inoculated from a syphilitic infant. The hair of the head or of the
eyebrows may fall out. The syphilitic onychia is not uncommon. Enlarge-
ment of the glands is not so frequent in the congenital as in the acquired
disease. When the cutaneous lesions are marked, the contiguous glands can
usually be felt. As pointed out by Gee, the spleen is enlarged in many cases.
The condition may persist for a long time. Enlargement of the liver, though
often present, is less significant, since in infants it may be due to various
causes. These are among the most constant symptoms of congenital sj^hilis,
and usually arise between the third and twelfth weeks. Frequently they are
preceded by a period of restlessness and wakefulness, particularly at night.
Some authors have described a peculiar syphilitic cry, high-pitched and harsh.
Among rarer manifestations are hsemorrhages — the syphilis hcBmorrliagica
neonatorum. The bleeding may be subcutaneous, from the mucous surfaces,
or,^ when early, from the umbilicus. All of such cases, however, are not syphi-
litic, and the disease must not be confounded with the acute hsemoglobinuria
of new-born infants. E. Fournier has described a remarkable enlargement
of the subcutaneous veins.
(c) Late Manifestations. — Children with congenital syphilis rarely thrive.
Usually they present a wizened, wasted appearance, and a prematurely aged
face. In the cases which recover, the general nutrition may remain good and
the child may show no further manifestations of the disease; commonly, how-
ever, at the period of second dentition or at puberty the disease reappears.
Although the child may have recovered from the early lesions, it does not
develop like other children. Growth is slow, development tardy, and there are
facial and cranial characteristics which often render the disease recognizable
at a glance. A young man of nineteen or twenty may neither look older nor
be more developed than a boy of ten or twelve. Fournier describes this condi-
tion as infantilism. The forehead is prominent, the frontal eminences are
marked, and the skull may be very asymmetrical. The bridge of the nose is
depressed, the tip retrousse. The lips are often prominent, and there are
striated lines running from the corners of the mouth. The teeth are deformed
SYPHILIS. 271
and may present appearances which Jonathan Hutchinson claims are specific
and peculiar. The upper central incisors of the permanent set are the teeth
which give information. The specific alterations are — the teeth are peg-
shaped, stunted in length and breadth, and narrower at the cutting edge than
at the root. On the anterior surface the enamel is well formed, and not
eroded or honeycombed, x^t the cutting edge there is a single notch, usually
shallow, sometimes deep, in which the dentine is exposed.
Among late manifestations, particularly apt to appear about puberty, is
the interstitial Jceratitis, which usually begins as a slight steaminess of the
corneaB, which present a ground-glass appearance. It affects both eyes, though
one is attacked before the other. It may persist for months, and usually clears
completely, though it may leave opacities, which prevent clear vision. Iritis
may also occur. Of ear affections, apart from those which follow the pharyn-
geal disease, a form occurs about the time of puberty or earlier, in which deaf-
ness comes on rapidly and persists in spite of all treatment. It is unassoci-
ated with obvious lesions, and is probably labyrinthine in character. Bone
lesions, occurring oftenest after the sixth year, are not rare among the late
manifestations of hereditary syphilis. The tibiae are most frequently attacked.
It is really a chronic gummatous periostitis, which gradually leads to great
thickening of the bone. The nodes of congenital syphilis, which are often
mistaken for rickets, are more commonly diffuse and affect the bones of the
upper and lower extremities. They are generally symmetrical and rarely pain-
ful. They may occur late, even after the twenty-first year.
Joint lesions are rare. Glutton has described a symmetrical synovitis of
the knee in hereditary sjrphilis. Enlargement of the spleen, sometimes with
the lymph-glands, may be one of the late manifestations, and may occur either
alone or in connection with disease of the liver.
Gummata of the liver, brain, and kidneys have been found in late hered-
itary syphilis. General paresis may follow.
Is syphilis transmitted to the third generation? Opinion on this subject
has been divided. Occasionally cases of pronounced congenital syphilis are
met with in the children of parents who are perfectly healthy, and who have
not, so far as is known, had syphilis; and yet, as remarked by Coutts in re-
porting such a group of cases, they do not always bear careful scrutiny. E.
Fournier, in his L'Heredo-Syphilis Tardive (1907), cites interesting examples
which appear to prove the transmission to the third generation, and this
appears to be the view of the French syphilographers. Mr. Hutchinson is still
opposed to this view.
IV. Visceral Syphilis.
1. Syphilis of the Brain and Cord.
There are three anatomical changes in the central nervous system — ^new
growths, arteritis, and chronic degenerative (sclerotic) processes.
(1) The new formations or gummata form definite tumors, ranging in
size from a pea to a walnut, usually multiple and attached to the pia mater,
sometimes to the dura. Very rarely they are found unassociated with the
meninges. When small they present a uniform, translucent appearance, but
when large the centre undergoes a fibro-caseous change, while at the periphery
272 SPECIFIC INFECTIOUS DISEASES.
there is a firm, translucent, grayish tissue. They may resemble large tubercu-
lous tumors. The growths are most common in the cerebrum. They may be
multiple and may even attain a considerable size \rithout becoming caseous.
Occasionally gummata undergo cystic degeneration. In the cord large growths
are not so common.
In the neighborhood of the growths gummous meningitis occurs, in which
all the membranes are involved. This is more common at the base, about the
chiasma and the interpeduncular space, and along the Sylvian fissures.
(2) Arteritis, in the form of nodular tumors on the vessels, which may
break down or lead to rupture, or there is a progressive obliterative endarte-
ritis. Heubner's view of the specific character of these changes is disputed.
(3) Degenerative fibroid changes, not distinctive anatomically, but clin-
ically directly connected with the disease, are known as post- or meta-syphilitic.
Secondary Changes. — In the brain gummatous arteritis is one of the com-
mon causes of softening, which may be extensive, as when the middle cerebral
artery is involved^ or when there is a large patch of meningitis. In such
instances the process is really a meningo-encephalitis, and the symptoms are
due to the secondary changes, not directly to the gumma. In the neighborhood
of a gumma intense encephalitis or myelitis may occur, and within a few days
change the clinical picture.
Syphilitic disease of the nerve-centres occurs usually in the acquired form.
In the congenital cases the tumors usually occur early, but may be as late as
the twenty-first year. Of late years it has been recognized that the nervous
lesions may occur very early in the disease, even before the induration of the
primary sore has gone. In a majority of the cases brain symptoms come on
within three or four years after infection.
Symptoms. — The chief features of cerebral sj^hilis are those of tumor
cerebri, which will be considered later. They may be classified here as follows :
(1) Psychical features. A sudden and violent onset of delirium may be
the first symptom. In other instances prior to the occurrence of delirium
there have been headache, alteration of character, and loss of memory. The
condition may be accompanied by convulsions. There may be no neuritis, no
palsy, and no localizing symptoms.
(2) More commonly following headache, giddiness, or an excited state
which may amount to delirium, the patient has an epileptic seizure or a hemi-
plegic attack, or there is involvement of the nerves of the base. Some of these
cases display a prolonged torpor, a special feature of brain syphilis to which
both Buzzard and Heubner have referred, which may persist for as long as
a month.
(3) In some cases the clinical picture is that of general paralysis — demen-
tia paralytica.
(4) Many cases of cerebral sjrphilis display the symptoms of brain tumor
— ^headache, optic neuritis, vomiting, and convulsions. Of these symptoms
convulsions are the most important, and both Fournier and Wood have laid
-great stress on the value of this symptom in persons over thirty. The first
symptoms may, however, rather resemble those of embolism or thrombosis;
thus there may be sudden hemiplegia, with or without loss of consciousness.
The symptoms of spinal syphilis are extremely varied and may be caused
by large gummatous growths attached to the meninges, in "which case the
SYPHILIS. 273
features are those of tumor, by gummatous arteritis with secondary soften-
ing, by meningitis with secondary cord changes, or by scleroses occurring late
in the disease. Syphilitic myelitis will be considered under affections of the
spinal cord.
Diagnosis. — The history is of the first importance, but it may be extremely
difficult to get a trustworthy account. Careful examination should be made
for traces of the primary sore, for the cicatrices of bubo, for scars of the skin
eruption or throat ulcers, and for bone lesions. The character of the symp-
toms is often of great assistance. They are multiform, variable, and often
such as could not be explained by a single lesion; thus there may be anoma-
lous spinal symptoms or involvement of the nerves of the brain on both sides.
And lastly the result of treatment has a definite bearing on the diagnosis, as the
symptoms may clear up and disappear with the use of antisyphilitic remedies.
2. Syphilis of the Respiratory Organs.
1. Syphilis of the Trachea and Bronchi. — ^L. A. Conner (Am. Jour, of
Med. Sci., July, 1903) has analyzed 128 recorded cases of syphilis of the
trachea and bronchi. In 56 per cent of the cases the trachea was alone in-
volved. In only 10 per cent were characteristic lesions of syphilis found in
the lungs. Bronchial dilatation below the lesion was found in 15 per cent of
the cases. In ten of the cases the lesion occurred in congenital syphilis.
2. Syphilis of the Lung. — This is a very rare disease. In the 2,800 post
mortems at the Johns Hopkins Hospital there were 12 cases with syphilitic
disease in the lungs ; in 8 of these the lesions were in congenital syphilis. In
11 cases there were definite gummata. Clinically the presence of syphilis
of the lung was suspected in three cases. Some years ago Fowler visited the
museums of the London hospitals and the Royal College of Surgeons, and
could find only twelve specimens illustrating syphilitic lesions of the lungs,
two of which are doubtful. For the most full and satisfactory consideration
of pulmonary syphilis, the reader is referred to chapter xxxvii of Fowler and
Godlee's work on Diseases of the Lungs.
It occurs under the following forms:
(1) The white pneumonia of the fcetus. This may affect large areas or
an entire lung, which then is firm, heavy, and airless, even though the child
may have been born alive. On section it has a grayish-white appearance—
the so-called white hepatization of Virchow. The chief change is in the
alveolar walls, which are greatly thickened and infiltrated, and the section is
like one of the pancreas — " pancreatization " of the lung. In the early stages,
for example, in a seven or eight months' fcetus, there may be scattered miliary
foci of this induration chiefly about the arteries. The air-cells are filled with
desquamated and swollen epithelium.
(2) In the form of definite gummata, which vary in size from a pea to
a goose-egg. They occur irregularly scattered through the lung, but, as a
rule, are more numerous toward the root. They present a grayish-yellow
caseous appearance, are dry and usually imbedded in a translucent, more or
less firm, connective tissue. In a case from my wards described by Council-
man, there was extensive involvement of the root of the lungs. Bands of con-
nective tissue passed inward from the thickened pleura, and between these
strands and surrounding the gummata there was in places a mottled red
274 SPECIFIC INFECTIOUS DISEASES.
pneumonic consolidation. In the caseous nodules there is typical hyaline
degeneration. In a few rare instances there are most extensive caseous gum-
mata with softening and formation of bronchiectatic cavities, and clinically
a picture of pulmonary tuberculosis without the presence of tubercle bacilli.
In one case, a man aged twenty-seven, admitted in April, 1903, had had for
a year cough and bloody expectoration and died of severe haemoptysis. Bacilli
were never found in the sputum. There were extensive caseous gummata
throughout both lungs, with much fibrous thickening, and in the lower lobe
of the right lung a cavity 3X5 cm. in diameter, on the wall of which a
branch of the pulmonary artery was eroded. This is the only instance among
my cases in which there was an extensive destruction of the lung tissue with
the clinical picture simulating pulmonary phthisis.
(3) A majority of authors follow Virchow in recognizing the fibrous in-
terstitial pneumonia at the root of the lung and passing along the bronchi and
vessels as probably syphilitic. This much may be said, that in certain cases
gummata are associated with these fibroid changes. Again, this condition
alone is found in persons with well-marked syphilitic history or with other
visceral lesions. It seems in many instances to be a purely sclerotic process,
advancing sometimes from the pleura, more commonly from the root of the
lung, and invading the interlobular tissue, gradually producing a more or less
extensive fibroid change. It rarely involves more than a portion of a lobe or
portions of the lobes at the root of the lung. The bronchi are often dilated.
Diagnosis. — It is to be borne in mind, in the first place, that hospital physi-
cians and pathologists the world over bear witness to the extreme rarity of
lung syphilis. In the second place, the therapeutic test upon which so much
reliance is placed is by no means conclusive. With pulmonary tuberculosis
there should now be no confusion, owing to the readiness with which the pres-
ence of bacilli is determined. Bronchiectasis in the lower lobe of a lung,
dependent upon an interstitial pneumonia of syphilitic origin, could not be
distinguished from any other form of the disease. In persons with well-
marked syphilitic lesions elsewhere, when obscure pulmonary symptoms occur,
or if there are signs of chronic interstitial pneumonia with dilated bronchi,
and no tubercle bacilli are present, the condition may possibly be due to syphi-
lis. So far as my experience goes, tuberculous phthisis occurring in a syphi-
litic subject has no special peculiarities. The lesions of syphilis and tubercu-
losis could of course coexist in a lung.
3. Syphilis of the Liver.
1. Inherited.— (a) Congenital— Gnhler in 1853 first described the dif-
fuse hepatitis, which occurs in a large percentage of all deaths in congenital
lues. \\Tiile there may be little or no macroscopical change, the liver pre-
serves its form and is usually enlarged, hard and resistant, and has a yellowish
color, compared by Trousseau to sole-leather, or by Gubler to that of flint.
Small grayish nodules may be seen on the section. In other cases there are
definite gummata with extensive sclerosis.
The child may be still-born or die shortly after birth, or it may be healthy
when born and the liver enlarges within a few weeks. The organ is firm;
the edge may be readily felt, usually far below the navel. The spleen is also
enlarged. The general features are those of a hypertrophic cirrhosis but
SYPHILIS. 275
jaundice and ascites are not common. Hochsinger (whose exhaustive work
on hereditary syphilis has just been completed, 1904) states that of 45 cases
recovery took place in 30.
(h) Delayed Congenital Syphilis. — The condition is by no means rare.
Of 132 cases of syphilis hereditaria tarda collected by Forbes, in 34 the liver
was involved. The children are nearly always ill-developed, sometimes with
marked clubbing of the fingers and showing signs of infantilism. Jaundice
is rare. The liver is usually enlarged, or it may show nodular masses.
2. Acquired Syphilis. — (a) In the secondary stages of the disease the
liver is not often involved. Jaundice may occur coincident with the rash
and with the enlargement of the superficial glands. Rolleston thinks it is
probably due to a catarrhal condition of the smaller ducts, part of a general
syphilitic hepatitis. There are cases in which it has passed on to a state of
acute yellow atrophy. The liver is slightly enlarged. The prognosis is gen*
erally good. (&) Tertiary lesions. The frequency with which the liver is in-
volved in syphilis in adults is very variously estimated. J. L. Allen, quoted
by Eolleston, found 37 cases of hepatic gummata among 11,629 autopsies at
St. George's Hospital, 27 cases in which cicatrices alone were present. Flex-
ner at the Philadelphia Hospital found 88 cases of hepatic syphilis among
5,088 autopsies. Among 2,300 autopsies at the Johns Hopkins Hospital (Pro-
fessor Welch) there have been 47 cases of syphilis of the liver, gummata in 19,
scars in 16, cirrhosis in 21 cases; 6 of the cases were congenital. My experi-
ence coincides with that of Einhorn and of Stockton, who hold that in the
United States the disease is by no means uncommon. In 21 cases the diagnosis
of syphilis of the liver was made clinically.
Anatomically the lesions may be either gummata or scars or a syphilitic
sclerosis. The gummata range in size from a pea to an orange. When small
they are pale and gray; the larger ones present yellowish centres; but later
there is a " pale, yellowish, cheese-like nodule of irregular outline, surrounded
by a fibrous zone, the outer edge of which loses itself in the lobular tissue, the
lobules dwindling gradually in its grasp. This fibrous zone is never very
broad; the cheesy centre varies in consistence from a gristle-like toughness to
a pulpy softness ; it is sometimes mortar-like, from cretaceous change "
(Wilks). They may form enormous tumors, as in the remarkable one figured
on page 351 in Eolleston's work on Diseases of the Liver. They may be felt
as large as an orange beneath the skin in the epigastrium and they may dis-
appear with the same extraordinary rapidity as the subcutaneous or periosteal
gumma. Macroscopically they may indeed at first look like massive cancer.
Extensive caseation, softening and calcification may occur. The syphilitic
scars are usually linear or star-shaped. They may be very numerous and
divide the liver into small sections — the so-called botyroid organ, of which a
remarkable example is figured in my Lectures on Abdominal Tumors. The
syphilitic cirrhosis is usually combined with gummata, or with marked scar-
ring in the portal canal, leading to lobulation of the organ, but the ordinary
multilobular cirrhosis is not common.
Symptoms. — In the first place the clinical picture may be that of cirrhosis
— slight jaundice, fever, portal obstruction, ascites. There may not be the
slightest suspicion of the syphilitic nature of the case. One of my patients
had been tapped thirteen times before admission to the hospital. The diag-
276 SPECIFIC INFECTIOUS DISEASES.
nosis was made by finding the gummata on the shins. She recovered
promptly.
In a' second group of cases the patient is anaemic, passes large quantities
of pale urine containing albumin and tube-casts; the liver is enlarged, per-
haps irregular, and the spleen also is enlarged. Dropsical symptoms may
supervene, or the patient may be carried off by some intercurrent disease.
Extensive amyloid degeneration of the spleen, the intestinal mucosa, and of
the liver, with gummata, are found.
Thirdly, in a very important group the symptoms are those of tumor of
the liver, causing pain and distress, and on examination an irregular mass
is discovered. The tumor may be large, causing a prominent bulging in the
epigastrium. N"aturally carcinoma is thought of, as there may be nothing to
suggest s}^hilis. In other cases the history or the presence of gummata else-
where should aid in the diagnosis. In other instances the rapid disappearance
under treatment even of a large visible tumor makes the s}^hilitic nature quite
positive. Lasth% in a few cases the irre.gular fever with enlargement and irreg-
ularity of the liver may suggest suppuration, or the uniform great enlargement
of the organ h}^ertrophic biliary cirrhosis, while there are some cases in which
the spleen is so greatly enlarged, the anemia so pronounced, and the liver small
and contracted that the diagnosis of splenic anaemia is made.
4, Syphilis of the Digestive Tract.
The oesophagus is very rarely affected. Stenosis is the usual result.
Syphilis of the stomach is excessively rare. Flexner has reported a remark-
able case in association with gummata of the liver. He has collected 14 cases
in the literature. Sj^hilitic ulceration has been found in the small intestine
and in the cscum.
The most common seat in this tract is the rectum. The affection is found
most commonly in women, and results from the growth of gummata in the
submucosa above the internal sphincter. The process is slow and tedious,
and may last for years before it finally induces stricture. The symptoms are
usually those of narrowing of the lower bowel. The condition is readily rec-
ognized by rectal examination. The history of gradual on-coming stricture,
the state of the patient, and the fact that there is a hard, fibrous narrowing,
not an elevated crater-like ulcer, usually render easy the diagnosis from malig-
nant disease. In medical practice these cases come under observation for
other symptoms, particularly amyloid degeneration; and the rectal disease
may be entirely overlooked, and only discovered post mortem.
5. Circulatory System.
Syphilis of the Heart.— K fresh, warty endocarditis due to syphilis is not
recognized, though occasionally in persons dead of the disease this form is
present, as is not uncommon in conditions of debility. Outgrowths on the
valves m connection with gummata have been reported by Janeway and others.
Loomis groups the lesions into: (1) Gummata, recent or old; (2) fibroid
induration, localized or diffuse; (3) amvloid degeneration; and (4) endar-
teritis obliterans. I. Adler claims that changes^in the blood-vessels of the
walls of the heart are common both in congenital and acquired syphilis, even
m cases without clinical symptoms or gross lesions.
SYPHILIS. 277
Rupture may take place, as in the cases reported by Dandridge and Nalty,
or sudden death, as in the cases of Cayley and Pearce Gould; indeed, sudden
death is frequent, occurring in 21 of 63 cases (Mracek).
Syphilis of the Arteries. — Syphilis plays an important role in arterio-scle-
rosis and aneurism. Its connection with these processes will be considered
later; here we shall refer only to the syphilitic affection of the smaller vessels,
which occurs in two forms :
(a) An obliterating endarteritis, characterized by a proliferation of the
subendothelial tissue. The new growth lies within the elastic lamina, and
may gradually fill the entire lumen ; hence the term obliterating. The media
and adventitia are also infiltrated with small cells. This form of endarteritis
described by Heubner is not, however, characteristic of syphilis, and its pres-
ence alone in an artery could not be considered pathognomonic. If, however,
there are gummata in other parts, or if the condition about to be described
exists in adjacent arteries, the process may be regarded as syphilitic.
(&) Gummatous Periarteritis. — With or without involvement of the in-
tima, nodular gummata may develop in the adventitia of the artery, produc-
ing globular or ovoid swellings, which may attain considerable size. They
are not infrequently seen in the cerebral arteries, which seem to be specially
prone to this affection. This form is specific and distinctive of syphilis.
Eeuter and Schmorl have found Spirochceta pallida in the syphilitic aortitis,
and Benda in gummatous arteritis of the cerebral vessels.
6. Renal Syphilis.
(a) Gummata occasionally are found in the kidneys, particularly in cases
in which there is extensive gummatous hepatitis. They are rarely numerous,
and occasionally lead to scattered cicatrices. Clinically the affection is not
recognizable.
(&) Acute Syphilitic Nephritis. — This condition has been carefully stud-
ied by the French writers and by Lafleur, of Montreal. It is estimated to
occur in the secondary stage in about 3.8 per cent, and may occur in from
three to six months, sometimes later, from the initial lesion. The outlook
is good, though often the albuminuria may persist for months; more rarely
chronic Bright's disease follows. In a few instances syphilitic nephritis has
proved rapidly fatal in a fortnight or three weeks. The lesions are not spe-
cific, but are similar to those in other acute infections.
7. Syphilitic Orchitis.
This affection is of special significance to the physician, as its detection
frequently clinches the diagnosis in obscure internal disorders. Syphilis occurs
in the testes in two forms :
(a) The gummatous growth, forming an indurated mass or group of
masses in the substance of the organ, and sometimes difficult to distinguish
from tuberculous disease. The area of induration is harder and it affects
the body of the testes, while tubercle more commonly involves the epididymis.
It rarely tends to invade the skin, or to break down, soften, and suppurate,
and is usually painless.
(&) There is an interstitial orchitis regarded as syphilitic, which leads
to fibroid induration of the gland and gradually to atrophy. It is a slow.
278 SPECIFIC INFECTIOUS DISEASES.
progressive change, coming on without pain, usually involving one organ
more than another.
Diagnosis, Treatment, etc.
General Diagnosis of Syphilis, — There is seldom any doubt concerning the
existence of syphilitic lesions. Syphilis is common in the community, and is no
respecter of age, sex, or station in life. It is possible that the primary sore
may have been of trifling extent, or urethral and masked by a gonorrhoea, and
the patient ma}' not have had severe secondary symptoms, but such instances
are extremely rare. Inquiries should be made into the history to ascertain if
the patient has had skin rashes, sore throat, or if the hair has fallen out. Care-
ful inspection should be made of the throat and skin for signs of old lesions.
Scars in the groins, the result of buboes, are uncertain evidences of syphilitic
infection. The cicatrices on the legs are often copper-colored, though this can
not be regarded as j^eculiar to syphilis. The bones should be examined for
nodes. In doubtful cases the scar of the primary sore may be found, or there
may be signs of atrophy or of hardening of the testes. In women, special
stress has been laid upon the occurrence of frequent miscarriages, which, in
connection with other circumstances, are always suggestive.
In the congenital disease, the occurrence within the first three months of
snuffles and skin rash is conclusive. Later, the characters of the syphilitic
facies, already referred to, often give a clew to the nature of some obscure
visceral lesion. Other distinctive features are the symmetrical development
of nodes on the bones, and the interstitial keratitis.
The Spirockceta pallida may be studied from the fresh lesion. After
cleaning carefully, serum is sucked out with a small Biers apparatus, and the
living spirochetes may be seen in the special " dark field " apparatus used for
the purpose.
Seram Diagnosis. — Wassermann's reaction has reached the clinical stage,
and in good hands may be accepted as valuable aid in diagnosis. It is ob-
tained in from 80 to 90 per cent of all cases of S3^philis with manifestations.
Observations are not altogether in accord, but such syphilographers as Neisser
and ringer are convinced of its practical value. The results in tabes and
dementia paralytica are very constant.
Therapeutic Test. — In a doubtful case, as, for example, an obstinate skin
rash, or an obscure tumor in the abdomen, antisyphilitic treatment may prove
successful, but this can not always be relied upon.
Prophylaxis. — Irregular intercourse has existed from the beginning of
recorded history, and unless man's nature wholly changes — and of this we
can have no hope— will continue. Eesisting all attempts at solution, the
social evil remains the great blot upon our civilization, and inextricably
blended with it is the question of the prevention of syphilis. Two measures
are available — the one personal, the other administrative.
Personal purity is the prophylaxis which we, as physicians, are especially
bound to advocate. Continence may be a hard condition (to some harder
than to others), but it can be borne, and it is our duty to urge this lesson
upon young and old who seek our advice in matters sexual. Certainly it is
better, as St. Paul says, to marry than to burn, but if the former is not feas-
SYPHILIS. 279
ible there are other altars than those of Venus upon which a young man may-
light fires. He may practise at least two of the five means by which, as the
physician Eondibilis counselled Panurge, carnal concupiscence may be cooled
and quelled — hard work of body and hard work of mind. Idleness is the
mother of lechery ; and a young man will find that absorption in any pursuit
will do much to cool passions which, though natural and proper, can not in
the exigencies of our civilization always obtain natural and proper gratification.
To carry out successfully any administrative measures seems hopeless, at
any rate, in our Anglo-Saxon civilization. The state accepts the responsi-
bility of guarding citizens against small-pox or cholera, but in dealing with
syphilis the problem has been too complex and has hitherto baffled solution.
Inspection, segregation, and regulation are difficult, if not impossible, to carry
out, and public sentiment is bitterly opposed to this plan. The compulsory
registration of every case of gonorrhoea and syphilis, with greatly increased
facilities for thorough treatment, offer a more acceptable alternative.
Treatment. — That the later stages which come under the charge of the
physician are so common, results, in great part, from the carelessness of the
patient, who, wearied with treatment, can not understand why he should
continue to take medicine after all the symptoms have disappeared; but, in
part, the profession also is to blame for not insisting more urgently that
acquired syphilis is not cured in a few months, but takes at least three years,
during which time the patient should be under careful supervision.
The discovery of the spirochete suggests prompt excision of the local
breeding spot — the chancre — and in apes this may be done successfully within
the first two weeks. Local treatment of the chancre with mercury will also
prevent the development of the disease in the ape. Much more important
is the fact that the virus is destroyed in the ape treated with atoxyl in from
three to ten days after inoculation, so that the animal may be reinfected.
These are practical points, the value of which in human practice will have
to be. tested. The atoxyl (metaroenic acid anilide) is strongly toxic to
protozoan parasites, as its use in sleeping sickness has shown. It may be
given intra-muscularly in doses of three grains every third day for ten days,
and then resumed. Good results have been reported by Lambkin with it.
Mercury may be given by the mouth in the form of gray powder, the
hydrargyrum cum creta, which Hutchinson recommends to be given in pills,
one-grain doses with a grain of Dover's powder. One pill from four to six
times a day will usually suffice. I warmly endorse the excellent results which
are obtained by this method, under which the patient often gains rapidly in
weight, and the general health improves remarkably. It may be continued
for months without any ill effects. Other forms given by the mouth are the
pilules of the biniodide (gr. ■^), or of the protiodide (gr. ^) , three times a
day. " If mercury be begun as soon as the state of the sore permits of diagno-
sis, and continued in small but adequate doses, the patient will usually escape
both sore throat and eruption" (Jonathan Hutchinson).
Inunction is a still more effective means. A drachm of the ordinary mer-
curial ointment is thoroughly rubbed into the skin every evening for six days ;
on the seventh a warm bath is taken, and on the eighth the mercurial course
is resumed. At least half an hour should be given to each inunction. It is
well to apply it at different places on successive days. The sides of the chest
280 SPECIFIC INFECTIOUS DISEASES.
and abdomen and the inner surfaces of the arms and thighs are the best
positions. .
The mercury may be given by direct injection into the muscles, it proper
precautions are taken in sterilizing the syringe, and if the injections are made
into the muscles, not into the subcutaneous tissue, abscesses rarely result.
One-third of a grain of the bichloride in twenty drops of water may be injected
once a week, or from one to two grains of calomel in glycerin (20 minims).
Still another method, greatly in vogue in certain parts of the Continent
and in institutions, is fumigation. It may be carried out effectively by means
of Lee's lamp. The patient sits on a chair -^Tapped in blankets, with the
head exposed. The calomel is volatilized and deposited with the vapor on the
patient's skin. The process lasts about twenty minutes, and the patient goes
to bed \\Tapped in blankets without washing or drying the skin.
A patient under mercurial treatment should avoid stimulants and live a
regular life, not necessarily abstaining from business. Green vegetables and
fruit should not be taken. Salivation is to be avoided. The teeth should be
cleansed twice a day, and if the gums become tender, the breath fetid, or the
tongue swollen and indented, the drug should be suspended for a week or
ten days.
In congenital syphilis the treatment of cases born with bullge and other
signs of the disease is not satisfactory, and the infants usually die within a
few days or weeks. The child should be nursed by the mother alone, or, if
this is not feasible, should be hand-fed, but under no circumstances should a
wet-nurse be employed. The child is most rapidly and thoroughly brought
under the influence of the drug by inunction. The mercurial ointment may
be smeared on the flannel roller. This is not a very cleanly method, and
sometimes rouses the suspicion of the mother. It is preferable to give the
drug by the mouth, in the form of gray powder, half a grain three times a day.
In the late manifestations associated with bone lesions, the combination of
mercury and iodide of potassium is most suitable and is well given in the form
of Gilbert's s}Tup, which consists of the biniodide of mercury (gr. j), of
potassium iodide (qSs.), and water (oij). Of this a dose for a child under
three is from five to ten drops three times a day, gradually increased. Under
these measures, the cases of congenital syphilis usually improve with great
rapidity. The medication should be continued at intervals for many months,
and it is well to watch these patients carefully during the period of second
dentition and at puberty, and if necessary to place them on specific treatment.
In the treatment of the visceral lesions of syphilis, which come more dis-
tinctly within the province of the physician, iodide of potassium is of equal
or even greater value than mercury. Under its use ulcers rapidly heal, gum-
matous tumors melt away, and we have an illustration of a specific action only
equalled by that of mercury in the secondary stages, by iron in certain forms
of ansemia, and by quinine in malaria. It is as a rule well borne in an initial
dose of 10 grains; given in milk the patient does not notice the taste. It
should be gradually increased to 30 or more grains three times a day. In
syphilis of the nervous system it may be used in still larger doses. Seguin,
who specially insisted upon the advantage of this plan, urged that the drug
should be pushed, as good effects were not obtained with the moderate doses.
When syphilitic hepatitis is suspected the combination of mercury and
GONORRHCEAL INFECTION. 281
iodide of potassium is most satisfactory. If there is ascites, Addison's pill
(as it is often called) of calomel, digitalis, and squills will be found very
useful. A patient of mine with recurring ascites, on whom paracentesis was
repeatedly performed and who had an enlarged and irregular liver, took this
pill for more than a year with occasional intermissions, and ultimately there
was a complete disappearance of the dropsy and an extraordinary reduction
in the volume of the liver. Occasionally the iodide of sodium is more satis-
factory than the iodide of potassium. It is less depressing and agrees better
with the stomach.
Syphilis and Marriage. — 'Upon this question the family physician is often
called to decide. He should insist upon the necessity of two full years elaps-
ing between the date of infection and the contracting of marriage. This, it
should be borne in mind, is the earliest possible limit, and marriage should be
allowed only if the treatment has been thorough and if at least a year has
passed without any manifestation of the disease.
Syphilis and Life Insurance. — An individual with syphilis can not be re-
garded as a first-class risk unless he can furnish evidence of prolonged and
thorough treatment and of immunity for two or three years from all mani-
festations. Even then, when we consider the extraordinary frequency of the
cerebral and other complications in persons who have had this disease and
who may even have undergone thorough treatment, the risk to the company
is certainly increased (see Bramwell, Clinical Studies, vol. i).
XXXII. GONORRHCEAL INFECTION.
Gonorrhoea, one of the most widespread and serious of infectious diseases,
presents many features for consideration. As a cause of ill-health and dis-
ability the gonococcus occupies a position of the very first rank among its
fellows. While the local lesion is too often thought to be trifling, in its singu-
lar obstinacy, in the possibilities of permanent sexual damage to the individ-
ual himself and still more in the " grisly troop " which may follow in its
train, gonorrhceal infection does not fall very far short of syphilis in impor-
tance.
The importance of the infection in children has been much dwelt upon
of late, particularly as in them the severer systemic lesions are liable to occur,
but more especially from the wide-spread and obstinate character of the epi-
demics in institutions. The gonococcus vaginitis and the ophthalmia are
very serious diseases in children's hospitals and in infants' homes. The story
of the gonococcus infection in the Babies' Hospital, New York, for the past
eleven years, as told by Holt (N. Y. Med. Jour., March, 1905), illustrates the
singular obstinacy of the infection. In spite of the greatest care and pre-
caution, there were in 1903 65 cases of vaginitis, with 2 of ophthalmia and
12 of arthritis. In 1904 there were 52 cases of vaginitis, only 16 of which
would have been recognized without the bacteriological examination. In all,
in the eleven years, there were 273 cases of vaginitis, only 6 with ophthalmia
and 26 with arthritis. Holt urges isolation and prolonged quarantine as the
only measures to combat successfully the disease.
The immediate and remote effects of the gonococcus may be considered
under —
282 SPECIFIC INFECTIOUS DISEASES.
I. The primary infection.
II. The spread in the genito-urinary organs by direct continuity of sur-
face.
III. Systemic gonorrhoea! infection.
The primary lesion we need not here consider, but we may call atten-
tion to the frequency of the complications, such as periurethral abscess, gon-
orrhoeal prostatitis in the male, and vaginitis, endocervicitis, and inflammation
of the glands of Bartholini in the female.
Perhaps the most serious of all the sequels of gonorrhoea are those
which result from the spread by direct continuity of tissue. Gonorrhoeal sal-
pingitis has been shown to be a not infrequent event. ]\Ietritis and ovaritis
are also occasionally met with, and peritonitis. The gonococcus has been
found in pure culture in cases of acute general peritonitis. Equally impor-
tant is the cystitis, which is probably much more frequently the result of a
mixed infection than due to the gonococcus itself. There is some danger of
extension upward through the ureters to the kidneys. The pyelitis, like the
cystitis, is usually a mixed infection.
Systemic Goxoeehceal Infection.
1. Gonorrhoeal Septicaemia and Pyaemia. — The fever associated with the
primary disease is not an indication of a general infection, but probably fol-
lows the absorption of toxins. The presence of the gonococcus may be demon-
strated in the blood, usually in connection with some local lesion, in which
the patient succumbed to an acute endocarditis. In one remarkable case fol-
lowing the gonorrhoea the patient had an irregular fever for weeks. The
gonococci were isolated from the blood in pure culture. There was no endo-
carditis and the patient recovered. Instances of severe, rapidly fatal general
infection in gonorrhoea are probably always associated with foci of suppura-
tion in the urinary tract. I examined in Montreal a remarkable case of rapid
gonorrhoeal sepsis in a young man, who within ten days of the primary lesion
was seized with severe chills and high fever. He rapidly became unconscious,
the fever persisted, and he fell into a condition of profound toxaemia and died
early on the morning of the fourth day from the chill. At the autopsy, which
was made about twelve hours after death, there was an acute urethritis and a
small prostatic abscess not more than 2 or 3 cm. in diameter. The blood was
fluid, tarry black, and unlike anything I have ever seen before or since.
Gonorrhoeal Endocarditis. — This is a frequent and serious complication.
Thayer has analyzed the cases which have been in my wards, 11 in all. In 6
the gonococci were demonstrated morphologically and by blood culture. In
2 cases they were demonstrated only by staining. In 2 instances there were
mixed infections. One case was t}^ical clinically and at autopsy.
Of other cardiac lesions, pericarditis occurred in 7 of the 30 fatal cases
collected by Thayer and Lazear.
Acute myocarditis was present in .Councilman's case.
2. Gonorrhoeal Arthritis.— In many respects this is the most damaging,
disabling, and serious of all the complications of gonorrhcea. Clement Lucas
has collected 23 cases in children, of which 18 followed ophthalmia neona-
torum. It occurs more frequently in males than in females. In a series of
252 cases collected by Korthrup, 230 were in males; 130 cases were between
GONORRHCEAL INFECTION. 283
twenty and thirty years of age. It occurs, as a rule, during an acute attack
of gonorrhoea. In 208 of ISTorthrup's series there was a urethral discharge
while in hospital. It may occur as the attack subsides, or even when it has
become chronic. A gonorrhoea! arthritis of great intensity may occur in a
newly married woman infected by an old gleet in her husband. As a rule,
many joints are affected. In Northrup's series three or more joints were
affected in 175 cases, one joint in 56 cases. It is peculiar in attacking certain
joints which are rarely involved in acute rheumatism, as the sterno-clavicular,
the inter- vertebral, the temporo-maxillary and sacro-iliac.
The anatomical changes are variable. The inflammation is often peri-
articular, and extends along the sheaths of the tendons. When effusion occurs
in the joints it rarely becomes purulent. It has more commonly the charac-
ters of a synovitis. About the wrist and hand suppuration sometimes occurs
in the sheaths. It has been suggested that the simple arthritis or synovitis
follows absorption of ptomaines from the urethral discharge, while the more
severe suppurating forms are due to infection with pus organisms. It has
now been definitely shown that the gonococcus itself may be present in the
inflamed joint or in the peri-arthritic exudate. The gonococcus may often
be obtained in pure culture from the joints. Sometimes the cultures are nega-
tive; in other instances there is a mixed infection with staphylococci or
streptococci.
Clinical Course. — Variability and obstinacy are the two most distinguish-
ing features. The following are the most important clinical forms :
(a) Arthralgic, in which there are wandering pains about the joints,
without redness or swelling. These persist for a long time.
(h) Poly arthritic, in which several joints become affected, just as in
subacute articular rheumatism. The fever is slight; the local inflammation
may fijc itself in one joint, but more commonly several become swollen and
tender. In this form cerebral and cardiac complications may occur.
(c) Acute gonorrhoeal arthritis, in which a single articulation becomes
suddenly involved. The pain is severe, the swelling extensive, and due chiefly
to peri-articular oedema. The general fever is not at all proportionate to the
intensity of the local signs. The exudate usually resolves, though suppura-
tion occasionally supervenes.
{d) Chronic Hydrarthrosis. — This is usually mono-articular, and is par-
ticularly apt to involve the knee. It comes on often without pain, redness,
or swelling. Formation of pus is rare. It occurred only twice in 96 cases
tabulated by ISTolen.
(e) Bursal and Synovial Form. — This attacks chiefly the tendons and
their sheaths and the bursDe and the periosteum. The articulations may not
be affected. The bursse of the patella, the olecranon, and the tendo Achillis
are most apt to be involved.
(/) Septiccemic. — In which with an acute arthritis the gonococci invade
the blood, and the picture is that of an intense septico-pysemia, usually with
endocarditis.
(g) The Painful Heel of Gonorrhcea. — This is a remarkable form of podo-
dynia due to local periosteal thickening and exostosis on the os calcis, causing
pain and great disability. Baer has demonstrated the gonococcus in the
periosteal lesion.
284 SPECIFIC INFECTIOUS DISEASES.
The disease is much more intractable than ordinary rheumatism, and
relapses are extremely common. It may become chronic and last for years.
Complications. — Iritis is not infrequent and may reciir with successive
attacks. The visceral complications are serious. Endocarditis, pericarditis,
and pleurisy may occur.
Treatment. — The salicylates are of very little service, nor do they often
relieve the pain in this affection. Iodide of potassium has also proved useless
in my hands, even in large doses. A general tonic treatment seems much
more suitable — quinine, iron, and, in the chronic cases, arsenic.
The local treatment is very important. The thermo-cautery may be used
to allay the pain and reduce the swelling. In acute cases, fixation of the
joints is very beneficial, and in the chronic forms, massage and passive motion.
Good results follow in a few cases the use of the dry hot air. The surgical
treatment of this affection, as carried out nowadays, is more satisfactory, and
I have seen strikingly good effects from incision and irrigation.
A vaccine treatment has been introduced, and good results are reported by
Cole and others.
XXXIII. TUBERCULOSIS.
I. General Etiology and Morbid Anatomy,
Definition. — An infective disease, caused by Bacillus tuberculosis, the
lesions of which are characterized by nodular bodies called tubercles or diffuse
infiltrations of tuberculous tissue which undergo caseation or sclerosis and
may finally ulcerate, or in some situations calcify.
Etiology. — 1. Zoological Distribution. — Tuberculosis is one of the most
widesjDread of maladies.
In cold-blooded animals it is rare, owing doubtless to temperature con-
ditions unfavorable to the development of the bacillus. Among reptiles in
confinement it is, however, occasionally seen (Sibley). In fowls it is an
extremely common disease, but there are differences in avian tuberculosis suf-
ficient to warrant its separation from the ordinary form.
Among domestic animals tuberculosis is widely but unevenly distributed.
Among ruminants, bovines are chiefly affected. In sheep the disease is very
rare. In pigs it is frequent in some parts of Europe. Horses are rarely
attacked. Dogs and cats are not prone to the disease, but cases are described
in which infection of pet animals has taken place from phthisical masters.
Among the semi-domestic animals, such as the rabbit and guinea-pig, the dis-
ease under natural conditions is rare, although these animals, particularly the
latter, are extremely susceptible to it when inoculated. Among apes and mon-
keys in the wild state, tuberculosis is unknown, but in confinement it is the
most formidable disease with which they have to contend.
The important etiological fact in connection with tuberculosis in animals
is the widespread occurrence of the disease in bovines, from which class we
derive nearly all the milk and a very large proportion of the meat used for
food.
2. General Statistics of the Disease in Man. — Tuberculosis is the
most universal scourge of the human race. It prevails more particularly in
the larger cities and wherever the population is massed together. Irving
TUBERCULOSIS. 285
Fisher estimates (1908) that the death-rate at present in the United States
is 164 per 100,000 living, that the deaths in 1906 were 138,000, and that of
those alive at present 5,000,000 would die of the disease. In England and
Wales the deaths due to tuberculous disease in 1903 were 58,107, 11.3 per cent
of the total mortality.
Geographical position has very little influence. The disease is perhaps
more prevalent in the temperate regions than in the tropics, but altitude is a
more potent factor than latitude; in the high regions of the Alps and Andes
and in the central plateau of Mexico the death-rate from tuberculosis is
very low.
Race. — The American Indians' have a death-rate more than double that
of the whites. The negroes in the Southern States also have an extraordi-
narily high death-rate, particularly in the cities. The Irish, both at home
and in the United States, are more prone to the disease than other European
races. The rate in Ireland has increased, and in America the mortality is
double that of the next highest European race. The. Italians in the large
American cities show a very high death-rate. The Jews everywhere have a
low mortality from consumption — about one-half that of Christians — which
Fishberg attributes to their adaptation to city life for the past 2,000 years.
The Decrease of Tuberculosis. — There has been everywhere a remarkable
diminution in the death-rate from the disease. The United States Census
Eeport shows a decrease of 9.4 per cent of the general death-rate in 1900 over
1890, and a decrease of 33.4 per cent in the death-rate from consumption.
The English reports also show a progressive decrease. It is more particularly
in the larger cities that there has been the most striking fall in the mortality.
This was well brought out for London by Beevor's careful study, while in
New York between 1887 and 1903, a period of sixteen years, there has been
a decrease in the total tuberculous death-rate of 40 per cent (Biggs). In
Massachusetts the rate has declined from 3.901 per million inhabitants in
1851 to 1.595 in 1903 (S. W. Abbott).
3. Bacillus Tuberculosis. — Eegarded as contagious in olden time, and
always in certain countries, Villemin first placed the infective nature of tuber-
culosis on a solid experimental basis. Cohnheim and Salomonsen confirmed
his results. Finally, after years of work, came the isolation of the tubercle
bacillus by Koch, who demonstrated its invariable association with the dis-
ease. The investigations which he had previously made upon anthrax and
experimental traumatic infections, by perfecting the methods of research,
paved the way for this brilliant discovery. His preliminary article * and his
more elaborate later work f should be carefully studied by any one who wishes
to appreciate the value of scientific methods. It forms one of the most mas-
terly demonstrations of modern medicine. Its thoroughness appears in the
fact that in the years which have elapsed since its appearance the innumerable
workers on the subject have not, so far as I know, added a solitary essential
fact to those presented by Koch.
Morphological Characters. — The tubercle bacillus occurs usually as a short,
fine rod, often slightly bent or curved, and has an average length of nearly
half the diameter of a red blood-corpuscle (3 to 4 /a) ; more rarely it shows
* Berliner klinische Wochenschrift, 1883.
f Mittheilungen a. d. k. Gesundheitsamte, Bd. 3.
286 SPECIFIC INFECTIOUS DISEASES.
lateral outgrowths or simple branches. When stained it often presents a
beaded appearance, which some have attributed to the presence of spores.
With the basic aniline dyes it stains slowly, except at the body tempera-
ture, but retains the dye after treatment with acids — a characteristic which
it is now known to share with several other bacterial species — the bacillus
leprEB, bacillus smegmatis, the grass and dung bacilli of Moeller, and the butter
bacillus of Eabinowitsch.
Modes of Growth. — It grows on blood-serum, glycerin-agar, bouillon, or
on potato — most readily on the first. The cultures must be kept at blood-
heat. They grow slowly, and do not appear until about the end of the second
week. The colonies form thin, grayish-white, dry, scale-like or Avrinkled
masses on the surface of the culture medium. Successive inoculations may be
made from the cultures, and at the end of an indefinite series material from
one of them inoculated into a guinea-pig will produce tuberculosis.
Variations. — (a) In Form. — The small branching forms are found not
infrequently in tuberculous lesions. More complex structures, resembling the
" Driisen " of the actinomyces are described, and involution forms are not
uncommon, particularly the small, oval, or round deeply staining bodies known
as Schron's capsules.
(&) Specific Varieties. — In 1901 Koch startled the scientific world with
the statement that the bacillus of bovine tuberculosis did not cause human
tuberculosis, and that the bacillus of human tuberculosis did not cause tuber-
culosis in cattle. At the Washington Congi-ess (1908) he admitted that they
were not distinct species, but differed from each other in certain characteristics,
wliich have been pointed out by Theobald Smith. The researches of von
Behring, Eavenel, and the English Commission have shown that it is possible
to cause tuberculosis in cattle with the bacillus from man; and there are many
cases in man caused by accidental infection from cattle. Bacillus tuberculosis
avium appears in more irregular forms and produces only local inflammatory
processes in mammals. Possibly infection with it may sometimes occur in man.
Composition and Products. — Tubercle bacilli contain water, various pro-
teids, fats (to which the peculiar staining reaction is due), a carbohydrate
resembling glycogen, cellulose, free and combined nucleic acid, and ash
(P. A. Levene). Koch's tuberculin is a proteid glycerin extract from the
bacilli.
Distribution of the Bacilli. — The bacilli are found in all tuberculous
lesions; in some in great abundance, in others sparsely. They are particu-
larly numerous in actively growing tubercles, but in the chronic processes of
lymph-glands and of the joints they are scanty. When a tuberculous focus
communicates with a vein or with lymph-vessels, the bacilli may be spread
widely throughout the body. In old lesions they may not be found in the sec-
tions, and the demonstration of the true nature may be possible only by culture
or inoculation. They are present in the blood in many cases. Large amounts
must be used for the cultures. Jousset has isolated them in 11 of 35 cases of
tuberculosis.
The Bacilli outside the Body. — Patients with advanced pulmonary tuber-
culosis throw of in the expectoration countless millions of the bacilli daily.
From a patient with moderately advanced disease, the amount of whose expec-
toration was from 70 to 130 cc. daily, Xuttall estimated that there were in
TUBERCULOSIS. 287
sixteen counts, between January lOtli and March 1st, from one and a half
to four and a third billions of bacilli thrown off in the twenty-four hours.
These figures emphasize the danger associated with phthisical sputa unless
most carefully dealt with. When expectorated and allowed to dry, the sputum
rapidly becomes dust, and is distributed far and wide. Cornet collected the
dust from the walls and bedsteads of various localities, and determined its
virulence or innocuousness by inoculation into susceptible animals. Material
was gathered from 21 wards of 7 hospitals, 3 asylums, 2 prisons, from the sur-
roundings of 62 phthisical patients in private practice, and from 29 other
localities in which tuberculous patients were only transient frequenters (out-
patient departments, streets, etc.). Of 118 dust samples from hospital wards
or the rooms of phthisical patients, 40 were infective and produced tubercu-
losis. Negative results were obtained with the 29 dust samples from the
localities occasionally occupied by consumptives. Virulent bacilli were ob-
tained from the dust of the walls of 15 out of 21 medical wards. It is inter-
esting to note that in 2 wards with many phthisical patients the results were
negative, indicating that the dust in such regions is not necessarily infective.
The infectiousness of the dust of the medical and surgical divisions of a hos-
pital is in the proportion of 76.6 to 12.5. In a room in which a tuberculous
woman had lived the dust from the wall in the neighborhood of the bed was
infective six weeks after her death. No bacilli were found in the dust of an
inhalation-chamber for consumptives. The experiments of Straus at the
Charite • Hospital, Paris, are important. In the nostrils of 29 assistants,
nurses, and ward-tenders he placed plugs of cotton-wool to collect the dust
of the wards. In 9 of the 29 cases these contained tubercle bacilli and proved
infective to animals. The question of the increase of tuberculosis among the
permanent residents of health resorts frequented by consumptives is one of
great interest. Gardiner has studied the problem at Colorado Springs, in
which for twenty years tuberculous patients have been living, and he finds
the number of cases of tuberculosis originating in the city to be very small.
Pseudo-tuberculosis. — While lesions resembling the nodules of tuberculosis,
but due to a variety of bacteria, protozoa, and nematodes, are not uncom-
mon in animals, pseudo-tuberculous processes are very rare in human beings.
Flexner has described, under the name pseudo-tub eixulo sis hominis strepto-
thrica, a condition in human beings in which the lungs presented the appear-
ance of a caseous pneumonia and numerous tubercle-like nodules existed in
the peritonaeum. The micro-organism found in the lesions was a strepto-
thrix, which differed greatly from the known forms of the bacillus tuberculosis
and streptothrix aetinomyces.
4. Modes of Infection. — (a) Hereditary Transmission. — The possible
methods of transmission of the germ in direct inheritance are three — trans-
mission by the sperm, transmission by the ovum, and transmission through
the blood by means of the placenta.
There is no clinical evidence to support the view that direct transmission
can occur through the sperm. In order that the disease could be transmitted
by the sperm it would be necessary that the tubercle bacilli should lodge in
the individual spermatozoon which fecundates the ovum. The chances that
such a thing could occur are extremely small, looking at the subject from
a numerical point of view, although we know that tubercle bacilli do occa-
288 SPECIFIC INFECTIOUS DISEASES.
sionally exist in the semen; they become still smaller when we consider that
the spermatozoon is made up of nuclear material, which the tubercle bacillus
is never known to attack. Experimentation is all opposed to sperm transmis-
sion, the work of Gartner and others showing that the young of healthy
female rabbits impregnated by tuberculous males are never tuberculous, even
though the females themselves often contract the disease.
The possibility of transmission by the ovum must be accepted. Baum-
garten has in one instance been able to detect the tubercle bacillus in the
ovum of a female rabbit which he had artificially fecundated with tubercu-
lous semen. The work of Pasteur on pehrine has shown the possibility of this
form of transmission in the lower forms, though the question as to what effect
such inoculation would have upon the human ovum can not of course be
answered.
Probably the almost constant method of transmission in congenital tuber-
culosis is through the blood current, the tubercle bacilli penetrating by way
of the placenta. Certain authors hold that in these cases the placenta itself
is invariably the seat of tuberculosis, and tubercles, indeed, have been demon-
strated in several cases; but there are undoubted instances in which, with an
apparently sound placenta, both the placental blood and the foetal organs
contained tubercle bacilli, notwithstanding the fact that the organs also
appeared normal.
Possible Latency of the Tubercle Oerms. — Baumgarten and his followers
assume that the tubercle bacilli can lie latent in the tissues and subsequently
develop when, for some reason or other, the individual resistance is lowered.
He likens such cases of latent tuberculosis to the late hereditary forms of
s}^hilis, and explains the lack of development of the germs by the greater
resisting power of the tissues of children. Baumgarten bases his belief in
germ transmission upon two main factors — the great frequency of the disease
in early life and the localization of tuberculous lesions in children.
The mortality from tuberculosis in the first years of life is relatively high.
Of 2,576 autopsies made on children, 27.8 per cent who died in the first year
were tuberculous (Botz). Of 182 autopsies on children one year or under, 17
were tuberculous (Comby). The localization of tuberculous lesions in chil-
dren in the bones or joints is very common, Cnopp's statistics showing that
out of 298 tuberculous children of from a few days to twelve years of age, 147
had bone or joint tuberculosis, and only 8 of these showed evidence of vis-
ceral disease. Baumgarten is of the opinion that the accidental conveyance
of tubercle bacilli to these points would not account for such a large propor-
tion of cases, and expresses the view that the bacilli have been present since
birth and have developed when favorable conditions offered. The evidence in
favor of Baumgarten's view is both clinical and experimental.
The clinical evidence exists in the form of undoubted cases of congenital
tuberculosis. Warthin and Cowie in a recent study conclude that there are
only five undoubted cases. A large proportion of those reported are doubtful,
as the diagnosis rested on anatomical appearances without the detection of
the bacilli.
A number of laboratory workers have been able to show that congenital
tuberculosis can be produced experimentally, the most prominent of these
being Gartner, who was able to cause tuberculosis in young mice by inocu-
TUBERCULOSIS. 289
lating the mother with tuberculosi.?, into either the peritoneal cavit}^ or tlie
blood stream. Maffucci showed that after injecting eggs with avian tubercu-
losis the disease may remain latent in the chick for weeks or even months.
Against Baumgarten's theory are the facts that the percentage of cases of
congenital tuberculosis is extremely small, and that in the great majority of
instances the organs of foetuses born of tuberculous mothers give negative
results when inoculated into guinea-pigs.
The statistics of pulmonary tuberculosis with reference to hereditary trans-
mission have been put on a new basis by the studies of Karl Pearson. For-
merly, the disease itself was believed to be transmitted, but we know now
that this is most exceptional. It is another matter with the soil — is there a
special disposition of tissue favorable to the development of the more or less
ubiquitous germ? On this point Pearson concludes from his researches (Sta-
tistics of Pulmonary Tuberculosis, Dulan & Co., London, 1907) that "the
diathesis of pulmonary tuberculosis is certainly inherited, and the intensity
of the inheritance is sensibly the same as that of any normal physical char-
acter yet investigated in man. Infection probably plays a necessary part,
but in the artisan classes of the urban populations of- this country (England)
it is doubtful if their members can escape the risks of infection, except by
the absence of diathesis — i. e., the inheritance of what amounts to a counter-
disposition." Another point of interest brought out by Pearson is that whether
we deal with all tuberculosis stocks or only with those having no parental
history, the elder children, particularly the first and second, are subject to
tuberculosis at a much higher rate than the younger members — " if this special
incidence in the earlier born be found to be true of other forms of patholog-
ical inheritance, we have a very serious factor of national deterioration intro-
duced by the growing limitations of the family."
While the demonstration of the contagiousness of tuberculosis has in some
quarters intensified the dread with which the disease is regarded, the terrible
Ate of hereditary transmission has been in great part abolished, to the great
gain of suffering humanity.
(&) Inoculation. — The infective nature of tuberculosis was first demon-
strated by Villemin, who showed conclusively in 1865 that it could be trans-
mitted to animals by inoculation. The beautiful experiments of Cohnheim
and Salomonsen, who produced tuberculosis in the eyes of guinea-pigs and
rabbits by inoculating fresh tubercle into the anterior chamber, confirmed and
extended Villemin's original observations and paved the way for the reception
of Koch's announcement. It is now universally conceded that only tubercu-
lous matter can produce, when inoculated, tuberculosis. In man tuberculosis
is not often transmitted by inoculation, and when it does occur the disease
usually remains local. This mode of infection is seen in persons whose occu-
pation brings them in contact with dead bodies or animal products. Demon-
strators of morbid anatomy, butchers, and handlers of hides are subject to a
local tubercle of the skin, which forms a reddened mass of granulation tissue,
usually capping the dorsal surface of the hand or finger. This is the so-called
post-mortem wart, the verruca necrogenica of Wilks. The demonstration of
its nature is shown by the presence of tubercle bacilli, and by inoculation
experiments in animals.
The statement that Laennec contracted phthisis from this source is prob-
20
290 SPECIFIC INFECTIOUS DISEASES.
ably false, since he did not die until twenty years after the inoculation and
in the interval presented no manifestations. The possibility, however, of gen-
eral infection must be borne in mind. Gerber reports that after accidental
inoculation in the hand from a case of phthisis he had for months a " Leichen-
tubercle," which was excised. Shortly afterward the lymph-glands of the
axilla became enlarged and painful, and when removed showed characteristic
tuberculous changes, with bacilli.
In the performance of the rite of circumcision children have been acci-
dentally inoculated. Infection in these cases is probably always associated
with disease in the operator, and occurs in connection with the habit of cleans-
ing the wound by suction.
Other means of inoculation have been described: as the wearing of ear-
rings, washing the clothes of phthisical patients, the bite of a tuberculous
subject, or inoculation from a cut by a broken spit-glass of a consumptive ; and
Czerny has reported two cases of infection by transplantation of skin.
It has been urged by the opponents of vaccination that tuberculosis, as
well as syphilis, may be thus conveyed, but of this there is no evidence.
Lymph of revaccinated consumptives is non-infective. Lupus has originated
at the site of vaccination in a few cases (C. Fox, Graham Little). It may
be said, on the whole, that inoculation in man plays a trifling role in the
transmission of tuberculosis.
(c) Infection ly Inhalation. — A belief in the contagiousness of pulmo-
nary tuberculosis has existed from the days of the early Greek physicians,
and has persisted among the Latin races. The investigations of Cornet afford
conclusive proof that the dust of a room or other locality frequented by
patients with pulmonary tuberculosis is infective. The bacilli are attached
to fine particles of dust and in this way gain entrance to the system through
the lungs.
Fliigge denies that the bacillus-containing dust is the dangerous element
in infection. Experimentally he has only succeeded in producing the disease
when there is some lesion in the respiratory tract. He thinks that the danger
of infection by the dry sputum is very improbable. On the other hand, he
thinks that the infection is chiefly conveyed by the free, finely divided par-
ticles of sputum produced in the act of coughing, and that these tiny frag-
ments are suspended in the atmosphere. Those who cough very much and
with the mouth open are most liable to infect the surrounding air.
It is well remarked by Cornet, "The consumptive in himself is almost
harmless, and only becomes harmful through bad habits." It has been fully
shown that the expired air of consumptives is not infective. The virus is
only contained in the sputum, which when dry is widely disseminated in the
form of dust, and constitutes the great medium for the transmission of the
disease.
Among the points urged in favor of this mode of infection are :
(1) Primary tuberculous lesions are in a majority of all cases connected
with the respiratory system. The frequency with which foci are met with
in the lungs and in the bronchial glands is extraordinary, and the statistics
of the Paris morgue show that a considerable proportion of all persons dying
of accident or by suicide present evidences of the disease in these parts. The
post-mortem statistics of hospitals show the same wide-spread prevalence of
TUBERCULOSIS. 291
infection through the air-passages. Biggs reports that more than 60 per cent
of his post mortems showed lesions of pulmonary tuberculosis. In 125 autop-
sies at the Foundling Hospital, New York, the bronchial glands were tuber-
culous in every case. In adults the bronchial glands may be infected and the
individual remain in good health. H. P. Loomis found in 8 of 30 cases in
which there were no signs of old or recent tuberculous lesions that the bron-
chial glands were infective to rabbits.
(2) The greater prevalence of tuberculosis in institutions in which the
residents are confined and restricted in the matter of fresh air and a free
open life — conditions which would favor, on the one hand, the presence of the
bacilli in the atmosphere, and, on the other, lower the vital resistance of the
individual. The investigations of Cornet upon the death-rate from consump-
tion among certain religious orders devoted to nursing give some striking
facts in illustration of this. In a review of 38 cloisters, embracing the aver-
age number of 4,028 residents, among 2,099 deaths in the course of twenty-
five years, 1,320 (62.88 per cent) were from tuberculosis. In some cloisters
more than three-fourths of the deaths are from this disease, and the mortal-
ity in all the residents, up to the fortieth year, is greatly above the average,
the increase being due entirely to the prevalence of tuberculosis. It has been
stated that nurses are not more prone to the disease than other individuals, but
Cornet says that of 100 nurses deceased, 63 died of tuberculosis. The more
perfect the prophylaxis and hygienic arrangements of an asylum or institu-
tion, the lower the death-rate froin tuberculosis. The mortality in prisons
has been shown by Baer to be four times as great as outside. The death-rate
from phthisis is estimated at 15 per cent of the total mortality, while in
prisons it constitutes from 40 to 50 per cent, and in some countries, as Austria,
over 60 per cent. Flick has studied the distribution of the deaths from
tuberculosis in a single city ward in Philadelphia for twenty-five years. His
researches go far to show that it is a house disease. About 33 per cent of
infected houses have had more than one case. Less than one-third of the
houses of the ward became infected with tuberculosis during the twenty-five
years prior to 1888. Yet more than one-half of the deaths from this disease
during the year 1888 occurred in those infected houses. There are, however,
opposing facts. The statistics of the Brompton Consumption Hospital show
that doctors, nurses, and attendants are rarely attacked. Dettweiler claims
that no case of tuberculosis has been contracted among his nurses or attend-
ants at Falkenstein. On the other hand, in the Paris hospitals tuberculosis
decimates the attendants.
(3) Special danger is believed to exist when the contact is very intimate,
as between man and wife. Until recently nearly all writers have held that
under these circumstances the husband or wife is much more likely subse-
quently to die of tuberculosis. Upon the figures of the late Ernest Pope, of
Saranac, Karl Pearson bases the following conclusions: (a) There is some sen-
sible but slight infection between married couples ; ( & ) this is largely obscured
or forestalled by the fact of infection from outside sources; (c) the liability
to the infection depends on the presence of the necessary diathesis; (d) assorta-
tive mating probably accounts for at least two-thirds, and infective action not
more than one-third of the whole correlation observed in these cases. There
are cases in which this source of infection seems to play an important role.
292 SPECIFIC INFECTIOUS DISEASES.
(d) Infection by Ingestion. — The work of the past few years has shown
that we have taken too restricted a view in supposing infection in tubercu-
losis to be chiefly through the lungs. There are two other channels, the ton-
sils and the intestines, both of great importance.
Tonsillar Infection. — The frequency of involvement of these glands has
been shown by Schlenker, Arthur Latham, and Walsham. The bacilli pass
to the glands of the neck and of the mediastinum, and reach the circulation
through the lymph-channels. Or an infected bronchial gland becomes adher-
ent to a branch of the pulmonary artery; if a large number of bacilli escape,
miliary tuberculosis follows; if only a small number, they reach the lungs,
at the apices of which they fmd conditions suitable for their growth. Through
this tonsillar-cervical route bacilli may gain entrance without causing local
disease at the portal of entry. It is a common method of infection in chil-
dren, causing the " scrofulous " glands of the neck.
Intestinal Infection. — Behring announced in 1903 that pulmonary tuber-
culosis could be induced through intestinal infection, and he further main-
tained that milk fed to infants was the chief cause of consumption in adults,
the infection remaining latent. Behring's first contention was supported by
Eavenel and others, who produced pulmonary tuberculosis in animals by feed-
ing experiments, and it was demonstrated that the intestinal surface itself
might remain intact. This does away with the objection raised by Koch
that if infection through the milk of tuberculous cattle were common, primary
intestinal tuberculosis should be more frec|uent, whereas in ten years among
3,10-1 cases of tuberculosis in children there were only 16 of primary bowel
infection. Eecent experiments have shown in a striking manner how the
lungs act as filters for particles absorbed from the intestines. Vansteenberghe
and Grysez have produced anthracosis of the lungs by introducing china-ink
emulsion directly into the stomach (see Anthracosis, p. 631). They found
a remarkable difference in young and adult guinea-pigs, in the former the
carbon particles were filtered out by the mesenteric glands, while the lungs
remained free; in the latter the glands were unaffected, but the lungs were
carbonized. Calmette and Guerin, repeating the experiments of Eavenel with
improved technique, have shown how easily the lungs may be infected through
the intestinal route without leaving the slightest trace of disease of the bowel
itself. Behring's view of the importance of infection through the intestinal
route has thus received the strongest support, and many go so far as to main-
tain that a majority of all cases of phthisis originate in this manner. The
truth is that this ubiquitous bacillus is not particular, and gains entrance
through many portals — throat, lungs, and intestines. The important matter
for the individual is the nature of the soil on which it falls.
Of foods, milk alone is a common source of infection, particularly in the
large cities. In Xew York, Hess found tubercle bacilli in 16 per 'cent of
107 specimens! The ordinary commercial pasteurization does not kill them.
The flesh of tuberculous animals is rarely dangerous.
5. Conditions Influencing Infection. — (a) General. — Environment is
an all-important predisposing factor. Dwellers in cities are much more prone
to the disease than residents of the country. Not only is the liability to infec-
tion very much greater, but the conditions of life are such that the powers
of resistance are apt to be weakened. As already stated, sunlight is one of
TUBERCULOSIS. 293
the most powerful agents in destroying the tubercle bacillus, so that in im-
perfectly ventilated dwellings and workshops, and in residences in close, dark
alleys, and in tenement houses the liability to infection is very much increased.
The influence of environment was never better demonstrated than in the now
well-known experiment of Trudeau, who found that rabbits inoculated with
tuberculosis if confined in a dark, damp place without sunlight and fresh air
rapidly succumbed, while others treated in the same way, but allowed to run
wild, either recovered or showed very slight lesions. The occupants of
prisons, asylums, and poorhouses, too often, indeed, in barracks and large
workshops, are in the position of Trudean's rabbits in the cellar, and under
conditions most favorable to foster the development of the bacilli which may
have lodged in their tissues. The frequent respiration of air already breathed,
upon which MacCormac of Belfast laid so much stress, appears to render the
lungs less capable of resisting infection.
The observations of Henry I. Bowditeh in this country and of Buchanan
in England show that the disease prevails more widely in the wet, ill-drained
districts — an increase which is associated with heightened vulnerability and
greater liability to catarrhal affections of all kinds. Gordon of Exeter has
shown that the mortality is high in regions exposed to strong rainy winds.
The influence of the dwelling has been already referred to in connection with
Flick's work. No single condition is of greater importance than that which
relates to the proper arrangement and ventilation of the dwelling house.
(&) Individual Predisposition. — The fathers of medicine, more particu-
larly Hippocrates, Aretseus, and Galen, laid great stress upon the bodily con-
formation of those prone to consumption. A great deal was written on the
so-called habitus phthisicus, which Hippocrates described in the following
terms : " The form of body peculiar to subjects of phthisical complaints was
the smooth, the whitish, that resembling the lentil ; the reddish, the blue-eyed,
the leuco-phlegmatic ; and that with the scapulge having the appearance of
wings." Undoubtedly the long, narrow, flat chest with depressed sternum is
commonly enough seen in tuberculous patients, but there are only too many
individuals with perfectly well-shaped chests who fall victims annually to
the disease. The tuberculous or scrofulous diathesis, upon which formerly
so much stress was laid, is now regarded simply as an indication of a type
of conformation in which the tissues are more vulnerable and less capable of
resisting infection. Beneke's investigations on the viscera of phthisical
patients indicate that the heart is relatively small, the arteries proportionately
narrow, and the pulmonary artery relatively wider than the aorta. He sug-
gests that this may lead to increase in the intrapulmonary blood pressure,
and so favor catarrhal processes. The lung volume he found relatively greater
in those affected with tuberculosis. A study of the composite portraiture of
pulmonary tuberculosis has been made by Gallon and Mahomed. In 443
patients they separated two types of face — one ovoid and narrow, the other
broad and coarse-featured. This corresponds in an interesting way to the
diathetic states formerly recognized — namely, the tuberculous, with thin skin,
bright eyes, oval face, and long, thin bones; and the scrofulous, with thick
lips and nose, opaque skin, large, thick bones, and heavy figure. These con-
ditions, on which so much stress was formerly laid, indicate, as Fagge states,
nothing more than delicacy of constitution, incomplete growth, and imperfect
294 SPECIFIC INFECTIOUS DISEASES.
dovolopmcnt. Sir A. E. Wright lias shown that the natural protective ele-
ments, the opsonins, of tlie hlood are low in tuberculous patients, whose phago-
cytic index is also very much below the normal standard.
(c) Influence of Age. — Xo age is exempt. The disease is met with in
the suckling and in the octogenarian. Pulmonary tuberculosis occurs most
frequently, as stated by Hippocrates, from the eighteenth to the thirty-fifth
year. From the fifth to the tenth year individuals are less prone to the dis-
ease. Barbier and Bondin (1908) have studied the frequency of tuberculosis
in children up to the fifteenth year in the Paris Hospitals. Of 1,364, 396
were tuberculous, 31 per cent. At different ages different organs are more
prone to be involved. During the first decade the bones, meninges, and IjTuph-
glands are more frequently affected than at subsequent periods.
(d) Sex. — The infiuence of sex is very slight. Women are perhaps some-
what more frequently attacked than men, possibly from the fact that in a
more sedentary, indoor life they are more liable to infection. Pregnancy and
lactation also are two conditions which are apt to lower, perhaps, the resistance
of the organism.
(e) Race. — (See page 285.)
(f) Influence of Occupation. — The characteristics of an employment
which tends to make tuberculosis unusually prevalent may be thus summa-
rized : a low rate of wage, unsanitary surroundings, exposure to dust, excessive
physical exertion, close confinement indoors, exposure to excessive heat, temp-
tations to intemperance, with long and irregular hours (L. Brandt).
{g) Certain local conditions influence infection, among which the follow-
ing are the most important:
The influence of catarrh of the respiratory passages in pulmonary tuber-
culosis is well recognized. How often is a neglected cold blamed as the
starting-point of the disease ! It seems to act by lowering the resistance and
favoring the conditions which enable the bacilli either to enter the system or,
when once in it, to grow. The liability of children to lymphatic tuberculosis
is probably associated with the common catarrhal processes in the tonsils,
throat, and bronchi.
Certain of the specific fevers predispose to tuberculosis, among which
measles and whooping-cough stand pre-eminent. They are often associated
with a bronchial catarrh. In some of the cases it is probably not a fresh
infection which follows, but the blazuig of a smouldering fire. Typhoid fever,
influenza, variola, and syphilis are all believed to favor the occurrence of the
disease. Diabetes, as is well known, very often terminates in pulmonary
tuberculosis, particularly in young persons.
Chronic heart-disease, arterio-sclerosis, aneurism of the aorta, forms of
chronic nephritis, cirrhosis of the liver, and the various forms of cerebro-
spinal sclerosis, all are conditions which favor infection. It is remarkable
in how many of the subjects of these disorders in general hospital practice the
fatal event is a terminal acute tuberculosis, most frequently of the serous
membranes. Subjects of congenital or acquired contraction of the orifice of
the pulmonary artery usually die of tuberculosis. On the other hand, mitral
valve disease, particularly stenosis, is stated to antagonize the disease (J. E.
Graham). In children catarrhal entero-colitis probably favors the origin of
tabes mesenterica.
TUBERCULOSIS. 295
The influence of haemoptysis and pleurisy will be referred to later.
Trauma. — The relation of injury to tuberculosis is well known. A blow
upon the chest may cause a pulmonary or pleural tuberculosis; injury to
the knee, a tuberculous arthritis ; a blow on the head, tuberculous meningitis.
Probably in these cases the injured part is for a time a locus minoris resisten-
tice, and if bacilli are present they may receive a stimulus to growth or under
the altered conditions become capable of multiplying. The whole question
is very fully discussed by Stern in his work on the relation of internal disease
to injury. The relation of surgical intervention in local tuberculosis to the
generalization of the disease is important. An existing lesion may be aggra-
vated, and fresh local lesions may appear, and, most serious of all, acute mil-
iary tuberculosis may follow.
General Morbid Anatomy and Histology of Tuberculous Lesions. — (1)
Distribution of the Tubercles in the Body. — The organs of the body are
variously affected by tuberculosis. In adults, the lungs may be regarded as
the seat of election; in children, the lymph-glands, bones, and joints. In
1,000 autopsies there were 275 cases with tuberculous lesions. With but two
or three exceptions the lungs were aflected. The distribution in the other
organs was as follows : Pericardium, 7 ; peritonasum, 36 ; brain, 31 ; spleen, 33 ;
liver, 13 ; kidneys, 33 ; intestines, 65 ; heart, 4 ; and generative organs, 8.
The tuberculosis which comes under the care of the surgeon has a differ-
ent distribution, as shovni by the following figures from the Wiirzburg clinic.
Among 8,873 patients, 1,287 were tuberculous, with the following distribu-
tion of lesions: Bones and joints, 1,037; lymph-glands, 196; skin and con-
nective tissues, 77; mucous membranes, 10; genito-urinary organs, 30.
(2) The Changes produced by the Tubercle Bacilli.
{a) The Nodular Tubercle. — The body which we term a " tubercle " pre-
sents in its early formation nothing distinctive or peculiar, either in its com-
ponents or in their arrangement. Identical structures are produced by other
parasites, such as the actinomyces, and by the strongjdus in the lungs of sheep.
The researches of Baumgarten have enabled us to follow in detail the evo-
lution of a tubercle.
(a) The multiplication of the tubercle bacilli, which is rapid and is ac-
companied by their dissemination in the surrounding tissues partly by growth,
partly in the lymph currents.
(^) The multiplication of the fixed cells, especially those of connective
tissue and the endothelium of the capillaries, and the gradual production from
them of rounded, cuboidal, or polygonal bodies with vesicular nuclei — the epi-
thelioid cells — inside some of which the bacilli are soon seen.
(y) Prom the vessels of the infected focus, leucocytes, chiefly polynuclear,
migrate in numbers and accumulate about the focus of infection. They do
not survive. Many undergo rapid destruction. Later, as the little tuber-
cle grows, the leucocytes are chiefly of the mononuclear variety (lymphocytes),
which do not undergo the rapid degeneration of the polynuclear forms.
(8) A reticulum of fibres is formed by the fibrillation and rarefaction
of the connective-tissue matrix. This is most apparent, as a rule, at the
margin of the growth.
(e) In some, but not all, tubercles giant cells are formed by an increase
in the protoplasm and in the nuclei of an individual cell, or possibly by the
296 SPECIFIC INFECTIOUS DISEASES.
fusion of several cells. The giant cells seem to be in inverse ratio to the
number and virulence of the bacilli. In lupus, joint tuberculosis, and scrofu-
lous glands, in which the bacilli are scanty, the giant cells are numerous;
■while in miliarv tubercles and all lesions in which the bacilli are abundant the
giant cells are few in number.
The bacilli then cause, in the first place, a proliferation of the fixed ele-
ments, with the production of epithelioid and giant cells; and, secondly, an
inflammatory reaction, associated with exudation of leucocytes. How far the
leucocytes attack and destroy the bacilli has not been definitely settled —
Metschnikoff claiming, Baumgarten denying, an active phagocj^tosis.
(3) The Degexeeatiox of Tubercle. — (a) Caseation. — At the central
part of the growth, owing to the direct action of the bacilli or their products,
a process of coagulation necrosis goes on in the cells, which lose their outline,
become irregular, no longer take stains, and are finally converted into a
homogeneous, structureless substance. Proceeding from the centre outward,
the tubercle may be gradually converted into a yellowish-gray body, in which,
however, the bacilli are still abundant. Xo blood-vessels are found in them.
Aggregated together these form the cheesy masses so common in tuberculosis,
which may undergo softening, fibroid limitation (encapsulation), or calci-
fication.
(&) Sclerosis. — "With the necrosis of the cell elements at the centre of the
tubercle, hyaline transformation proceeds, together with great increase in the
fibroid elements ; so that the tubercle is converted into a firm, hard structure.
Often the change is rather of a fibro-caseous nature; but the sclerosis pre-
dominates. In some situations, as in the peritonasum, this seems to be the
natural transformation of tubercle, and it is by no means rare in the lungs.
In all tubercles two processes go on: the one — caseation — destructive and
dangerous; and the other — sclerosis — conservative and healing. The ulti-
mate result in a given case depends upon the capabilities of the body to restrict
and limit the growth of the bacilli. There are tissue-soils in which the baciUi
are, in aU probability, killed at once — the seed lias fallen hy the wayside.
There are others in which a lodgment is gained and more or less damage done,
but finally the day is with the conservative,- protecting forces — the seed has
fallen upon stony ground. Thirdly, there are tissue-soils in which the bacilli
grow luxuriantly, caseation and softening, not limitation and sclerosis, prevail,
and the day is with the invaders — the seed has fallen upon good ground.
The action of the bacilli injected directly into the blood-vessels illustrates
many points in the histology and pathologv^ of tuberculosis. If into the vein
of a rabbit a pure culture of the bacilli is injected, the microbes accumulate
chiefly va the liver and spleen. The animal dies usually within two weeks,
and the organs apparently show no trace of tubercles. Microscopically, in
both spleen and liver the young tubercles in process of formation are very
numerous, and karyokinesis is going on in the liver-cells. After an injection
of a more dilute culture, or one whose virulence has been mitigated by age,
instead of d}ring within a fortnight the animal survives for five or six weeks',
by which time the tubercles are apparent in the spleen and liver, and often
in the other organs.
(4) The diffused Inflammatory Tubercle.— This is most frequently
seen in the lungs. Only a great master like Yirchow could have won the pro-
TUBERCULOSIS. 297
fession from a belief in the unity of phthisis, which the genius of Laennec had
on anatomical ground, announced. Here and there a teacher, as Wilson Fox,
protested, but the heresy prevailed, and we repeated the striking aphorism of
Niemeyer, " The greatest evil which can happen to a consumptive is that he
should become tuberculous." It was thought that the products of any simple
inflammation might become caseous, and that ordinary catarrhal pneumonia
terminated in phthisis. It was peculiarly fitting that from Germany, in which
the dualistic heresy arose, the truth of Laennec's views should receive incon-
testable proof, in the demonstration by Koch of the etiological unity of all the
various processes known as tuberculous and scrofulous.
Infiltrated tubercle results from the fusion of many small foci of infec-
tion— so small indeed that they may not be visible to the naked eye, but which
histologically are seen to be composed of scattered centres, surrounded by areas
in which the air-cells are filled with the products of exudation and of the
proliferation of the alveolar epithelium. Under the influence of the bacilli,
caseation takes place, usually in small groups of lobules, occasionally in an
entire lobe, or even the greater part of a lung. In the early stage of the
process, the tissue has a gray gelatinous appearance, the gi-ay infiltration of
Laennec. The alveoli contain a sero-fibrinous fluid with cells, and the septa
are also infiltrated. These cells accumulate and undergo coagulation necrosis,
forming areas of caseation, the infiltratioti tuherculeuse jaune of Laennec,
the scrofulous or cheesy pneumonia of later writers. There may also be a
diffuse infiltration and caseation without any special foci, a wide-spread tuber-
culous pneumonia induced by the bacilli.
After all, the two processes are identical. As Baumgarten states : " There
is no well-marked difference between miliary tubercle and chronic caseous
pneumonia. Speaking histologically, miliary tuberculosis is nothing else than
a chronic caseous miliary pneumonia, and chronic caseous pneumonia is noth-
ing but a tuberculosis of the lungs."
(5) Secondary Inflammatory Processes. — (a) The irritation caused
by the bacilli invariably produces an inflammation which may, as has been
described, be limited to exudation of leucocytes and serum, but may also be
much more extensive, and which varies with varying conditions. We flnd,
for example, about the smaller tubercles in the lungs, pneumonia — either
catarrhal or fibrinous, proliferation of the connective-tissue elements in the
septa (which also become infiltrated with round cells), and changes in the
blood and lymph-vessels.
(6) In processes of minor intensity the inflammation is of the slow reac-
tive nature, which results in the production of a cicatricial connective tissue
which limits and restricts the development of the tubercles and is the essential
conservative element in the disease. It is to be remembered that in chronic
pulmonary tuberculosis much of the fibroid tissue which is present is not in
any way associated with the action of the bacilli.
(c) Suppuration. Do the bacilli themselves induce suppuration? In
so-called cold tuberculous abscess the material is not histologically pus, but
a debris consisting of broken-down cells and cheesy material. It is moreover
sterile — that is, does not contain the usual pus organisms. The products of
the tubercle bacilli are probably able to induce suppuration, as in joint and
bone tuberculosis pus is frequently produced, although this may be due to a
21
29g SPECIFIC INFECTIOUS DISEASES.
mixed infection. Koch states that the " tuberculin " is one of the best agents
for the production of experimental suppuration. In tuberculosis of the lungs
the suppuration is largely the result of an infection with pus organisms.
II. Acute Miliaet Tuberculosis.
The modern knowledge of this remarkable form dates from the statement
of Buhl (1856), that miliary tuberculosis is a specific infection dependent on
the presence in the body of an unencapsulated yellow tubercle, or a tubercu-
lous cavity in the lung ; and that it bears the same relation to the primary lesion
as pyaemia does to a focus of suppuration.
Carl Weigert established the truth of this brilliant conception by demon-
strating the association of miliary tuberculosis with tuberculosis of the blood-
vessels. There are two groups of vessel tubercle — the tuberculous periangitis
in which there is invasion of the adventitia^ and the endangitis in which the
tubercles start in the intima. The parts most frequently affected are the
pulmonary veins and the thoracic duct, less often the jugular vein, the supra-
renal and the vena cava superior, and the sinuses of the dura mater, the aorta,
and the endocardium. To the branches of the pulmonary veins it is not
uncommon to find caseous glands adherent, penetrating the walls and show-
ing a growth of miliary tubercles in the intima. A special interest belongs
to tuberculosis of the thoracic duct, first accurately described and thoroughly
studied by Sir Astley Cooper. Benda in a series of 19 cases of vessel tuber-
culosis found in many instances an enormous number of bacilli, particularly
in the caseous tubercles of the thoracic duct.
Access of the bacilli to the blood may take place by the perforation of an
extra-vascular caseous mass into the lumen, or by the softening and ulcera-
tion of a focus of tuberculous endangitis. The bacilli do not increase in the
blood, but settle in the different organs, producing a generalized tuberculosis,
of which Weigert recognizes three t}^es or grades : I. The acute general mil-
iary tuberculosis, in which the various organs of the body are stuffed with
miliary and submiliary nodules. II. A second form characterized by a small
number of tubercles in one or many organs. III. The occurrence of numer-
ous tuberculous foci widely spread throughout the body, but in a more chronic
form; the tubercles are larger and many are caseous. It is the chronic gen-
eralized tuberculosis of children. Transitional forms between these groups
occur. In the first variety, which we are here considering, there is an erup-
tion into the circulation of an enormous number of bacilli. Benda suggests
in explanation of the profound toxaemia seen in certain cases (the typhoid
form) that in addition the blood is surcharged with toxins from a large caseous
focus which has eroded the vessel.
Clinical Forms.
The cases may be grouped into those with the symptoms of an acute gen-
eral infection — ^the typhoid form ; cases in which pulmonary sjTnptoms pre-
dominate; and cases in which the cerebral or cerebrospinal symptoms are
marked — tuberculous meningitis.
Other forms have been recognized, but this division covers a large majority
of the cases.
TUBERCULOSIS. 299
Taking any series of cases it will be found that the meningeal form of acute
tuberculosis exceeds in numbers the cases with general or marked pulmonary
symptoms.
1. General or Typhoid Form. — Symptoms. — The patient here presents
the symptoms of a profound infection with few if any local signs. The cases
simulate and are frequently mistaken for typhoid fever. After a period of
failing health, with loss of appetite, the patient becomes feverish and weak.
Occasionally the disease sets in more abruptly, but in many instances the
anamnesis closely resembles that of typhoid fever. Nose-bleeding, however,
is rare. The temperature increases, the pulse becomes rapid and feeble, the
tongue dry; delirium becomes marked and the cheeks are flushed. The pul-
monary symptoms may be very slight; usually bronchitis exists, but is not
more severe than is common with typhoid fever. The pulse is seldom dicrotic,
but is rapid in proportion to the pyrexia. Perhaps the most striking feature
of the temperature is the irregularity; and if seen from the outset there is
not the steady ascent noted in typhoid fever. There is usually an evening
rise to 103°, sometimes 104°, and a morning remission of from two to three
degrees. Sometimes the pyrexia is intermittent, and the thermometer may
register below normal during the early morning hours. The inverse type of
temperature, in which the rise takes place in the morning, is held by some
writers to be more frequent in general tuberculosis than in other diseases. In
rare instances there may be little or no fever. On two occasions I have had
a patient admitted to my wards in a condition of profound debility, with a
history of illness of from three to four weeks' duration, with rapid pulse,
flushed cheeks, dry tongue, and very slight elevation in temperature, in whom
(post mortem) the condition proved to be general tuberculosis. In one in-
stance there was tolerably extensive.disease at the right apex. Eeinhold, from
Baumler's clinic, has recently called attention to these afebrile forms of acute
tuberculosis. In 9 of 52 cases there was no fever, or only a transient rise.
In a considerable number of these cases the respirations are increased
in frequency, particularly in the early stage, and there may be signs of diffuse
bronchitis and slight cyanosis. Cheyne-Stokes breathing occurs toward the
close.
Active delirium is rare. More commonly there are torpor and dulness,
gradually deepening into coma, in which the patient dies. In some cases
the pulmonary symptoms become more marked; in others, meningeal or cere-
bral features occur.
Diagnosis. — The differential diagnosis between general miliary tubercu-
losis without local manifestations and typhoid fever is extremely difficult. A
point of importance, to which reference has already been made, is the irregu-
larity of the temperature curve. The greater frequency of the respirations and
the tendency to slight cyanosis is much more common in tuberculosis. There
are cases, however, of typhoid fever in which the initial bronchitis is severe
and may lead to dyspnoea and disturbed oxygenation. The cough may be
slight or absent. Diarrhoea is rare in tuberculosis; the bowels are usually
constipated; but diarrhoea may occur and persist for days. In certain cases
the diagnosis has been complicated still further by the occurrence of blood
in the stools. Enlargement of the spleen occurs in general tuberculosis, but
is neither so early nor so marked as in typhoid fever. In children, however.
300 SPECIFIC INFECTIOUS DISEASES.
the enlargement may be considerable. The urine ma}^ show traces of albu-
min, and unfortunately Ehrlich's diazo-reaction, which is so constant in
typhoid fever, is also met with in general tuberculosis. The absence of the
characteristic roseola is an important feature. Occasionally in acute tubercu-
losis reddish spots may occur and for a time cause difficult}^, but they do not
come out in crops, and rarely have the characters of the true tj'phoid eruption.
Herpes is perhaps more common in tuberculosis. Toward the close, petechige
may appear on the skin, particularly about the wrists. A rare event is jaun-
dice, due possibly to the eruption of tubercles in the liver. It is to be remem-
bered that the lesions of acute tuberculosis and of t}^hoid fever have been
demonstrated in the same body.
A negative Widal test and the absence of typhoid bacilli in blood-cultures
may be of decisive importance in these doubtful cases. In very rare instances
tubercle bacilli have been found in the blood. Leucocytosis is more common
in miliary tuberculosis than in tj^phoid fever, in which leucopenia is the rule.
Careful examination of the eyes may show choroidal tubercles, though I have
never known a diagnosis made on their presence alone. In the fluid obtained
by lumbar puncture the tubercle bacilli may be abundant, even when there is
no active meningitis. In a few cases the bacilli have been found in the urine.
Blood-cultures have been occasionally successful.
2. Pulmonary Form. — Symptoms. — From the outset the pulmonary sjonp-
toms are marked. The patient may have had a cough for months or for
years without much impairment of health, or he may be known to be the
subject of chronic pulmonary tuberculosis. In other instances, particularly
in children, the affection follows measles or whooping-cough, and is of a dis-
tinctly broncho-pneumonic type. The disease begins with the symptoms of
diffuse bronchitis. The cough is marked, the expectoration muco-purulent,
occasionally rusty. Hsemoptv^sis has been noted in a few instances. From the
outset dyspnoea is a striking feature and may be out of proportion to the
intensity of the physical signs. There is more or less cyanosis of the lips and
finger-tips, and the cheeks are suffused. Apart from emphysema and the later
stages of severe pneumonia I know of no other pulmonary condition in which
the cyanosis is so marked. The physical signs are those of bronchitis. In
children there may be defective resonance at the bases, from scattered areas of
broncho-pneumonia; or, what is equally suggestive, areas of hyper-resonance.
Indeed, the percussion note, particularly in the front of the chest, in some
cases of miliary tuberculosis, is full and clear, and it will be noted (post mor-
tem) that the lungs are unusually voluminous. This is probably the result
of more or less wide-spread acute emphysema. On auscultatioia, the rales
are either sibilant and sonorous or small, fine, and crepitant. There may be
fine crepitation from the occurrence of tubercles on the pleura (Jiirgensen).
In children there may be high-pitched tubular breathing at the bases or toward
the root of the lung. Toward the close the rales may be larger and more
mucous. The temperature rises to 102° or 103°, and may present the inverse
type. The pulse is rapid and feeble. In the very acute cases the spleen is
always enlarged. The disease may prove fatal in ten or twelve davs, or may
be protracted for weeks or even months.
Diagnosis.— The diagnosis of this form offers less difficulty and is more
frequently made. There is often a history of previous cough, or the patient
TUBERCULOSIS. 301
is known to be the subject of local disease of the lung, or of the lymph-glands,
or of the bones. In children these symptoms following measles or Avhoop-
ing-cough indicate in the majority of cases acute miliary tuberculosis, with
or without broncho-pneumonia. Occasionally the sputum contains tubercle
bacilli.
The choroidal tubercle occurs in a limited number of cases and may help
the diagnosis. More importajit in an adult is the combination of dyspnoea
with cyanosis and the signs of a diffuse bronchitis. In some instances the
occurrence of cerebral symptoms at once gives a clew to the nature of the
trouble.
3. Meningeal Form (Tuberculous Meningitis, Basilar Meningitis) . — This
affection, which is also known as acute hydrocephalus or " water on the
brain," is essentially an acute tuberculosis in which the membranes of the
brain, sometimes of the cord, bear the brunt of the attack. Our first accurate
knowledge of this affection dates from the publication of Eobert Whytt's
Observations on the Dropsy of the Brain, Edinburgh, 1768. He studied 20
cases and divided the disease into three stages, according to the condition of
the pulse.
Though Guersant had as early as 1827 used the name granular menin-
gitis for this form of inflammation of the meninges, it was not until 1830
that Papavoine demonstrated the nature of the granules and noted their
occurrence with tubercles in other parts.
In 1833 and 1833, W. W. Gerhard, of Philadelphia, made a very careful
study of the disease in the Children's Hospital at Paris, and his publica-
tions, more than those of any other author, served to place the disease on
a firm anatomical and clinical basis.
There are several special etiological factors in connection with this form.
It is much more common in children than in adults. It is rare during the
first year of life, more frequent between the second and the fifth years. In a
majority of the cases a focus of old tuberculous disease will be found, com-
monly in the bronchial or mesenteric glands. In a few instances the affec-
tion seems to be primary in the meninges. It is very difficult, however, in
an ordinary post mortem to make an exhaustive search, and the lesion may
be in the bones, sometimes in the middle ear, or in the genito-urinary organs.
In those instances in which no primary focus has been discovered it has been
suggested that the bacilli reach the meninges through the cribriform plate of
the ethmoid from the upper part of the nostrils, but this is not probable.
Morbid Anatomy. — The meninges at the base are most involved, hence the
term basilar meningitis. The parts about the optic chiasm, the Sylvian fis-
sures, and the interpeduncular space are affected. There may be only slight
turbidity and matting of the membranes, and a certain stickiness with serous
infiltration; but more commonly there is a turbid exudate, fibrino-purulent
in character, which covers the structures at the base, surrounds the nerves,
extends into the Sylvian fissures, and appears on the lateral, rarely on the
upper, surfaces of the hemispheres. The tubercles may be very apparent,
particularly in the Sylvian fissures, appearing as small, whitish nodules on
the membranes. They vary much in number and size, and may be difficult
to find. The amount of exudate bears no definite relation to the abundance
of tubercles. The arteries of the anterior and posterior perforated spaces
302 SPECIFIC INFECTIOUS DISEASES.
should be carefully withdrawn and searched, as upon them nodular tubercles
may be found when not present elsewhere. In doubtful cases the middle cere-
bral arteries should be very carefully removed, spread on a glass plate with
a black background, and examined with a lens. The tubercles are then seen
as nodular enlargements on the smaller arteries. The lateral ventricles are
dilated (acute hydrocephalus) and contain a turbid fluid; the epend}Tna may
be softened, and the septum lucidum and fornix are usually broken doum.
The convolutions are often flattened and the sulci obliterated owing to the
increased intra-ventricular pressure. There is a tuberculous endarteritis with
the formation of intimal tubercles, due to implantation of bacilli from the
blood (Hektoen). Proliferation in the adventitia, with invasion of the media
and intima are common, forming nodular circumscribed tubercles. The
lumen of the vessel is narrowed and thrombosis may result. The meninges
are not alone involved, but the contiguous cerebral substance is more or less
oedematous and infiltrated with leucoc}ies, so that anatomically the condition
is in reality a meningo-enceplialitis.
There are instances in which the acute process is associated with chronic
meningeal tuberculosis; cases which may for months present the clinical pic-
ture of brain tumor.
Although in a majority of instances the process is cerebral, the spinal
meninges may also be involved, particularly those of the cervical cord. There
are cases indeed in which the sjTnptoms are chiefly spinal. A sailor, who had
fallen on the deck three weeks before his death, was admitted to the Montreal
General Hospital. He presented signs of meningitis, chiefly spinal, which
were naturally attributed to traumatism. The post mortem showed absence
of tubercles and lymph at the base of the brain, and an extensive eruption
of miliary tubercles with much turbid hTnph over the entire spinal meninges.
There were small cheesy masses at the apices of the lungs.
Stmpto:ms. — Tuberculous meningitis presents an extremely complex clini-
cal picture. It will be best to describe the form found in children.
Prodromal s}Tnptoms are common. The child may have been in failing
health for some weeks, or may be convalescent from measles or whooping-
cough. In many instances there is a history of a fall. The child gets thin,
is restless, peevish, irritable, loses its appetite, and the disposition may com-
pletely change. Symptoms pointing to the disease may then set in, either
quite suddenly with a convulsion, or more commonly with headache, vomit-
ing, and fever, three essential symptoms of the onset which are rarely absent.
The pain may be intense and agonizing. The child puts its hand to its head
and occasionally, when the pain becomes worse, gives a short, sudden cry, the
so-called hydrocephalic cry. Sometimes the child screams continuously until
utterly exhausted. I saw in West Philadelphia a case of basilar meningitis in
a girl of thirteen, who for three days, when not under the influence of a pow-
erful sedative or of chloroform, screamed at the top of her voice so as to be
heard a square or more away. The vomiting is without apparent cause, and
is independent of taking of food. Constipation is usually present. The fever
IS slight, but gradually rises to 102° or 103°. The pulse is at flrst rapid, subse-
quently irregular and slow. The respirations are rarelv altered. During
sleep the child is restless and disturbed. There may be tsvitchings of the mus-
cles, or sudden startings; or the child may wake up from sleep in great terror.
TUBERCULOSIS. 303
In this early stage the pupils are usually contracted. These are the chief
symptoms of the initial stage, or, as it is termed, the stage of irritation.
In the second period of the disease these irritative symptoms subside ; vom-
iting is no longer marked, the abdomen becomes retracted, boat-shaped or
carinated. The bowels are obstinately constipated, the child no longer com-
plains of headache, but is dull and apathetic, and when roused is more or less
delirious. The head is often retracted and the child utters an occasional cry.
The pupils are dilated or irregular, and a squint may develop. Sighing res-
piration is common. Convulsions may occur, or rigidity of the muscles of one
side or of one limb. The temperature is variable, ranging from 100° to
102.5°. A blotchy erythema is not uncommon on the skin. If the finger-nail
is drawn across the skin of any region a red line comes out quickly, the
so-called tache cerehrale, which, however, has no diagnostic significance.
In the final period, or stage of paralysis, the coma increases and the child
can not be roused. Convulsions are not infrequent, and there are spasmodic
contractions of the muscles of the back and neck. Spasms may occur in the
limbs of one side. Optic neuritis and paralysis of the ocular muscles may be
present. The pupils become dilated, the eyelids are only partially closed, and
the eyeballs are rolled up so that the corneas are only uncovered in part by
the upper eyelids. Diarrhoea may occur, the pulse becomes rapid, and the
child may sink into a typhoid state with dry tongue, low delirium, and invol-
untary passages of urine and fsces. The temperature often becomes sub-
normal, sinking in rare instances to 93° or 94°. In some cases there is an
ante-mortem elevation of temperature, the fever rising to 106°. The entire
duration of the disease is from a fortnight to three or four weeks. A leuco-
cytosis is not infrequently present throughout the disease.
There are cases of tuberculous meningitis which pursue a more rapid
course. They set in with great violence, often in persons apparently in good
health, and may prove fatal within a few days. In these instances, more
commonly seen in adi^lts, the convex surface of the brain is usually involved.
There are again instances which are essentially chronic and display symptoms
of a limited meningitis, sometimes with pronounced psychical symptoms, and
sometimes with those of cerebral tumor.
There are certain features which call for special comment.
The irregularity and slowness of the pulse in the early and middle stages
of the disease are points upon which all authors agree. Toward the close, as
the heart's action becomes weaker, the pulsations are more frequent. The
temperature is usually elevated, but there are instances in which it does not
rise in the whole course of the disease much above 100°. It may be extremely
irregular, and the oscillations are often as much as three or four degrees in
the day. Toward the close the temperature may sink to 95°, occasionally to
94°, or there may be hyperpyrexia. In a case of Baumler's the temperature
rose before death to 43.7° C.\ll0.7° F.).
The ocular symptoms of the disease are of special importance. In the
early stages narrowing of the pupils is the rule. Toward the close, with in-
crease in the intra-cranial pressure, the pupils dilate and are irregular.
There may be conjugate deviation of the eyes. Of ocular palsies the third
nerve is most frequently involved, sometimes with paralysis of the face, limbs,
and hypoglossal nerve on the opposite side (syndrome of Weber), due to a
304 SPECIFIC INFECTIOUS DISEASES.
lesion limited to the inferior and internal part of the crus. The changes in
the retinse are very important. Neuritis is the most common. According
to Gowers, the disk at first becomes full colored and has hazy outlines,
and the veins are dilated. Swelling and striation become pronounced, but
the neuritis is rarely intense. Of 26 cases studied by Garlick, in 6 the condi-
tion was of diagnostic value. The tubercles in the choroid are rare and much
less frequently seen during life than post-mortem figures would indicate.
Thus Litten found them (post mortem) in 39 out of 53 cases. They were
present in only 1 of the 26 cases of tuberculous meningitis examined by Gar-
lick. Heinzel examined with negative results 41 cases.
Among the motor symptoms convulsions are most common, but there are
other changes which deserve special mention. A tetanic contraction of one
limb may persist for several days, or a cataleptic condition. Tremor and athe-
toid movements are sometimes seen. The paralyses are either hemiplegias
or monoplegias. Hemiplegia may result from disturbance in the cortical
branches of the middle cerebral artery, occasionally from softening in the
internal capsule, due to involvement of the central branches. Of monoplegias,
that of the face is perhaps most common, and if on the right side it may occur
with aphasia. In two of my cases in adults aphasia occurred. Brachial mono-
plegia may be associated with it. In the more chronic cases the symptoms
persist for months, and there may be a characteristic Jacksonian epilepsy.
Kernig's sign is present as a rule (see Cerebro-spinal Fever).
The diagnosis of tuberculous meningitis is rarely difficult, and points
upon which special stress is to be laid are the existence of a tuberculous focus
in the body, the mode of onset and the symptoms, and the evidence obtained
on lumbar puncture. The fluid withdrawn is usually turbid, often sterile,
but, on centrifugalizing, the bacilli may be discovered. The cells are usually
small mononuclear lymphocytes.
The prognosis in this form of meningitis is always most serious. I have
neither seen a case which I regarded as tuberculous recover, nor have I seen
post-mortem evidence of past disease of this nature. Cases of recovery have
been reported by reliable authorities, but they are extremely rare, and there is
always a reasonable doubt as to the correctness of the diagnosis. The differ-
ential features and treatment will be considered in connection with acute
meningitis.
III. Tuberculosis of the Lymphatic System.
1. Tuberculosis of the Lymph-glands {Scrofula).
Scrofula is tubercle, as it has been shown that the bacillus of Koch is the
essential element. Formerly special attention was given to different types
of scrofula, of which two important forms were recognized — the sanguine, in
which the child was slightly built, tall, with small limbs, a fine clear skin,
soft silky hair, and was mentally very bright and intelligent; and the phleg-
matic ij^e, in which the child was short and thick-set, with coarse features
muddy complexion, and a duU, heavy aspect. It is not yet definitelv settled
whether the virus which produces the chronic tuberculous adenitis or ^scrofula
differs from that which produces tuberculosis in other parts, or whether it is
the local conditions m the glands which account for the slow development and
TUBERCULOSIS. 305
milder course. The experiments of Arloing would indicate that the virus was
attenuated or milder, for he has shown that the caseous material of a lymph-
gland killed guinea-pigs, while rabbits escaped. The guinea-pig, as is well
known, is the more susceptible animal of the two. The observations of Lin-
gard are still more conclusive, as showing a variation in the virulence of the
tubercle bacillus. Guinea-pigs inoculated with ordinary tubercle showed
lymphatic infection within the first week, and the animals died within three
months ; infected with material from scrofulous glands, the lymphatic enlarge-
ment did not appear until the second or third week, and the animals sur-
vived for six or seven months. He showed, moreover, that the virulence of the
infection obtained from the scrofulous glands increased in intensity by passing
through a series of guinea-pigs. In a certain number of cases the infection is
with the bovine germ, but exactly in what proportion, and with what special
clinical features have not yet been determined.
Tuberculous adenitis, met with at all ages, is more common in children
than in adults; and may occur in old age.
Tubercle bacilli are ubiquitous ; all are exposed to infection, and upon the
local conditions, whether favorable or unfavorable, depends the fate of those
organisms which find lodgment in our bodies. A special predisposing factor
in lymphatic tuberculosis is catarrh of the mucous membranes, which in itself
excites slight adenitis of the neighboring glands. In a child with constantly
recurring naso-pharyngeal catarrh, the bacilli which lodge on the mucous
membranes find in all probability the gateways less strictly guarded and are
taken up by the lymphatics and passed to the nearest glands. The impor-
tance of the tonsils as an infection-atrium has of late been urged. In condi-
tions of health the local resistance, or, as some would put it, the phagocytes,
would be active enough to deal with the invaders, but the irritation of a
chronic catarrh weakens the resistance of the lymph-tissue, and the bacilli are
enabled to grow and gradually to change a simple into a tuberculous adenitis.
The frequent association of tuberculous adenitis of the bronchial glands with
whooping-cough and with measles, and the frequent association of tubercle
in the mesenteric glands in children with intestinal catarrh, find in this way
a rational explanation. After all, as Yirchow pointed out, an increased vul-
nerability of the tissue, however brought about, is the important factor in the
disease.
The following are some of the features of interest in tuberculous ade-
nitis :
(a) The local character of the disease. Thus, the glands of the neck, or
at the bifurcation of the bronchi, or those of the mesentery, may be alone
involved.
(&) The tendency to spontaneous healing. In a large proportion of the
cases the battle which ensues between the bacilli and the protective forces is
long; but the latter are finally successful, and we find in the calcified rem-
nants in the bronchial and mesenteric lymph-glands evidences of victory.
Too often in the bronchial glands a truce only is declared and hostilities may
break out afresh in the form of an acute tuberculosis.
(c) The tendency of tuberculous adenitis to pass on to suppuration. The
frequency with which, particularly in the glands of the neck, we find the tuber-
culous processes associated with suppuration is a special feature of this form
306 SPECIFIC INFECTIOUS DISEASES.
of adenitis. In nearly all instances the pus is sterile. Whether the suppura-
tion is excited by the bacilli or by their products, or whether it is the result
of a mixed infection with pus organisms, which are subsequently destroyed,
has not been settled.
(d) The existence of an unhealed focus of tuberculous adenitis is a con-
stant menace to the organism. It is safe to say that in three-fourths of the
instances of acute tuberculosis the infection is derived from this source. On
the other hand, it has been urged that scrofula in childhood gives a sort of
protection against tuberculosis in adult life. We certainly do meet with many
persons of exceptional bodily vigor who in childhood had eidarged glands, but
the evidence which Marfan brings forward in support of this view is not con-
clusive.
Clinical Forms. — Gexeealized Tubeeculous Lymphadenitis. — In excep-
tional instances we find diffuse tuberculosis of nearly all the lymph-glands of
the body with little or no involvement of other parts. The most extreme cases
of it. which I have seen, have been in negro patients. Two well-marked cases
occurred at the Philadelphia Hospital. In a woman, the chart from April,
1888, until March, 1889, showed persistent fever, ranging from 101° to 103°,
occasionall}' rising to 104°. On December 16th the glands on the right side
of the neck were removed. After an attack of erysipelas, on February 17th,
she gradually sank and died ]\Iarch 5th. The lungs presented only one or two
puckered spots at the apices. The bronchial, retro-peritoneal, and mesenteric
glands were greatly enlarged and caseous. There was no intestinal, uterine,
or bone disease. The continuous high fever in this case depended apparently
upon the tuberculous adenitis, which was much more extensive than was sup-
posed during life. In these instances the enlargement is most marked in the
retro-peritoneal, bronchial, and mesenteric glands, but may be also present
in the groups of external glands. Occurring acutely, it presents a picture
resembling Hodgkin's disease. In a case which died in the Montreal General
Hospital this diagnosis was made. The cervical and axillary glands were
enormously enlarged, and death was caused by infiltration of the larjmx. In
infants and children there is a form of general tuberculous adenitis in which
the various groups of glands are successiveh^, more rarely simultaneously, in-
volved, and in which death is caused either by cachexia, or by an acute infec-
tion of the meninges.
Local Tuberculous Adenitis. — (a) Cervical. — This is the most com-
mon form met with in children. It is seen particularly among the poor and
those who live continuously in the impure atmosphere of badly ventilated
lodgings. Children in foundling hospitals and asjdums are specially prone to
the disease. In the United States it is most common in the negro race. As
already stated, it is often met with in catarrh of the nose and throat, or chronic
enlargement of the tonsils ; or the child may have had eczema of the scalp or
a purulent otitis.
The submaxillary glands are first involved, and are popularly spoken of
as enlarged l-erneh. They are usually larger on one side than on the other.
As they increase in size, the individual tumors can be felt; the surface is
smooth and the consistence firm. They may remain isolated, but more com-
monly they form large, knotted masses, over which the skin is, as a rule, freely
movable. In many cases the skin ultimately becomes adherent, and inflam-
TUBERCULOSIS. 307
mation and suppuration occur. An abscess points and, unless opened, bursts,
leaving a sinus which heals slowly. The disease is frequently associated with
coryza, with eczema of the scalp, ear, or lips, and with conjunctivitis or kera-
titis. Wlien the glands are large and growing actively, there is fever. The
subjects are usually anaemic, particularly if suppuration has occurred. The
progress of this form of adenitis is slow and tedious. Death, however, rarely
follows, and many aggravated cases in children ultimately get well. Not only
the submaxillary group, but the glands above the clavicle and in the posterior
cervical triangle, may be involved. In other instances the cervical and axil-
lary glands are involved together, forming a continuous chain which extends
beneath the clavicle and the pectoral muscle. With them the bronchial glands
may also be enlarged and caseous. Not infrequently the enlargement of the
supra-clavicular and axillary group of glands on one side precedes a tubercu-
lous pleurisy or pulmonary tuberculosis.
(h) Tracheo-hronchial. — The mediastinal lymph-glands constitute filters
in which lodge the various foreign particles which escape the normal phago-
cytes of bronchi and lungs. Among these foreign particles, and probably
attached to them, tubercle bacilli are not uncommon, and we find tubercles and
caseous matter with great frequency in this group. ISTorthrup found them in-
volved in every one of 127 cases of tuberculosis at the New York Foundling
Hospital. This tuberculous adenitis may, in the bronchial glands, attain the
dimensions of a tumor of large size. But even when this occurs there may
be no pressure sjrmptoms. In children the bronchial adenitis is apt to be
associated with suppuration. The effects of these enlarged glands are very
varied, and for full details the reader is referred to the elaborate section in
the TraiU of Barthez and Sannee (tome iii) . It is sufficient here to say that
there are instances on record of compression of the superior cava, of the pulmo-
nary artery, and of the azygos vein. The trachea and bronchi, though often
flattened, are rarely seriously compressed. The pneumogastric nerve may be
involved, particularly the recurrent laryngeal branch. More important really
are the perforations of the enlarged and softened glands into the bronchi or
trachea, or a sort of secondary cyst may be formed between the lung and the
trachea. Asphyxia has been caused by blocking of the larynx by a case-
ous gland which has ulcerated through the bronchus (Voelcker), and Cyril
Ogle has reported a case in which the ulcerated gland practically occluded
both bronchi. Perforations of the vessels are much less common, but the pul-
monary artery and the aorta have been opened. Perforation of the oesophagus
has been described in several cases. One of the most serious effects is infec-
tion of the lung or pleura by the caseous glands situated deep along the
bronchi. This may, as is often clearly seen, be by direct contact, and it may
be difficult to determine in some sections where the caseous bronchial gland
terminates and the pulmonary tissue begins. In other instances it takes place
along the root of the lung and is subpleural. Among other sequences may
be mentioned diverticulum of the oesophagus following adhesion of an enlarged
gland and its subsequent retraction; and, in the case of the anterior medi-
astinal and aortic groups, the frequent production of pericarditis, either by
contact or by rupture of a softened gland into the sac.
A serious danger is systemic infection, which takes place through the
vessels.
308 SPECIFIC INFECTIOUS DISEASES.
(c) Mesenteric; Tales mesenterica. — In this affection, the ahdominal
scrofula of old writers, the glands of the mesentery and retro-peritonaeum be-
come enlarged and caseate ; more rarely they suppurate or calcify. A slight
tuberculous adenitis is extremely common in children, and is often accidentally
found (post mortem) when the children have died of other diseases. It may
be a primary lesion associated with intestinal catarrh, or it may be secondary
to tuberculous disease of the intestines.
The statistics of abdominal tuberculosis show a great variation in different
localities. The small percentage in New York, less than one per cent of all
cases (Bovaird and Mt. Sinai Hospital figures), contrasts with the high fig-
ure, 18 per cent, for England, and the same has been demonstrated re-
cently for Scotland by John Thomson, 3.57 for Edinburgh and 4.51 for
Glasgow. The general involvement of the glands interferes seriously with
nutrition, and the patients are puny, wasted, and anaemic. The abdomen is
enlarged and tympanitic; diarrhoea is a constant feature; the stools are thin
and offensive. There is moderate fever, but the general wasting and debility
are the most characteristic features. The enlarged glands can not often be
felt, owing to the distended condition of the bowels. These cases are often
spoken of as consumption of the bowels, but in a majority of them the intes-
tines do not present tuberculous lesions. In a considerable number of the
cases of tabes mesenterica the peritonaeum is also involved, and in such the
abdomen is large and hard, and nodules may be felt.
In adults tuberculous disease of the mesenteric glands may occur as a
primary affection, or in association with pulmonary disease. Large tumors
may exist without tuberculous disease in the intestines or in any other part.
2. Tuberculosis of the Serous Membranes.
General Serous Membrane Tuberculosis (Polyorrhomenitis) . — The
serous membranes may be chiefly involved, simultaneously or consecutively,
presenting a distinctive and readily recognizable clinical type of tuberculosis.
There are three groups of cases. First, those in which an acute tuberculosis
of the peritonaeum and pleura occurs rapidly, caused by local disease of the
tubes in women, or of the mediastinal or bronchial lymph-glands. Secondly,
cases in which the disease is more chronic, with exudation into both perito-
naeum and pleurae, the formation of cheesy masses, and the occurrence of ulcer-
ative and suppurative processes. Thirdly, there are cases in which the pleuro-
peritoneal affection is still more chronic, the tubercles hard and fibroid, the
membranes much thickened, and with little or no exudate. In any one of
these three forms the pericardium may be involved with the pleurae and peri-
tonaeum. It is important to bear in mind that there may be in these cases
no visceral tuberculosis.
Tuberculosis oe the Pleura.— 1. Acute tuberculous pleurisy. It is dif-
ficult in the present state of our knowledge to estimate the proportion of
instances of acute pleurisy due to tuberculosis (see Acute Pleurisy). The
cases are rarely fatal. Here, too, there are three groups of cases : (a) Acute
tuberculous pleurisy with subsequent chronic course, (b) Secondary and ter-
minal forms of acute pleurisy (these are not uncommon in hospital practice).
And (c) a form of acute tuberculous suppurative pleurisy. A considerable
TUBERCULOSIS. 309
number of the purulent pleurisies, designated as latent and chronic, are
caused by tubercle bacilli, but the fact is not so widely recognized that there
is an acute, ulcerative, and suppurative disease which may run a very rapid
course. The pleurisy sets in abruptly, with pain in the side, fever, cough, and
sometimes with a chill. There may be nothing to suggest a tuberculous pro-
cess, and the subject may have a fine physique and come of healthy stock.
2. The subacute and chronic tuberculous pleurisies are more common. The
largest group of cases comprises those with sero-fibrinous effusion. The onset
is insidious, the true character of the disease is frequently overlooked, and in
almost every instance there are tuberculous foci in the lungs and in the bron-
chial glands. These are cases in which the termination is often in pulmonary
tuberculosis or general miliary tuberculosis. In a few cases the exudate
becomes purulent.
And, lastly, there is a chronic adhesive pleurisy, a primary proliferative
form which is of long standing, may lead to very great thickening of the mem-
brane, and sometimes to invasion of the lung.
Secondary tuberculous pleurisy is very common. The visceral layer is
always involved in pulmonary tuberculosis. Adhesions usually form and a
chronic pleurisy results, which may be simple, but usually tubercles are scat-
tered through the adhesions. An acute tuberculous pleurisy may result from
direct extension. The fluid may be sero-fibrinous or hasmorrhagic, or may
become purulent. And, lastl}^, a very common event in pulmonary tubercu-
losis is the perforation of a superficial spot of softening, and the production
of pyo-pneumothorax.
The general symptomatology of these forms will be considered under dis-
ease of the pleura.
Tuberculosis of the Pericardium. — Miliary tubercles may occur as a
part of a general infection, but the term is properly limited to those cases
in which, either as a primary or secondary process, there is extensive disease
of the membrane. Tuberculosis is not so common in the pericardium as in
the pleura and peritonaeum, but it is certainly more common than the litera-
ture would lead us to suppose. George Norris found 82 instances among
1,780 post mortems in tuberculous subjects.
We may recognize four groups of cases: First, those in which the condi-
tion is entirely latent, and the disease is discovered accidentally in individuals
who have died of other affections or of chronic pulmonary tuberculosis.
A second group, in which the symptoms are those of cardiac insufficiency
following the dilatation and hypertrophy consequent upon a chronic adhesive
pericarditis. The symptoms are those of cardiac dropsy, and suggest either
idiopathic hypertrophy and dilatation, or, if there is a loud blowing systolic
murmur at the apex, mitral valve disease, either insufficiency or stenosis.
There are cases of adherent pericardium in which a bruit is heard which
resembles the rumbling presystolic murmur (T. Fisher). The condition of
adherent pericardium is usually overlooked.
In a third group the clinical picture is that of an acute tuberculosis, either
general or with cerebro-spinal manifestations, which has had its origin from
the tuberculous pericardium or tuberculous mediastinal lymph-glands.
A fourth group, with symptoms of acute pericarditis, includes cases in
which the affection is acute and accompanied with more or less exudation
310 SPECIFIC INFECTIOUS DISEASES.
of a sero-fibrinous, ha>morrhagic, or purulent character. There may be no
suspicion whatever of the tuberculous nature of the trouble.
Tuberculosis of the Peritoneum. — In connection \nth miliary and
chronic pulmonary tuberculosis it is not uncommon to find the peritonaeum
studded with small gray granulations. They are constantly present on the
serous surface of tuberculous ulcers of the intestines. Apart from these con-
ditions the membrane is often the seat of extensive tuberculous disease, which
occurs in the following forms:
(1) Acute miliary tuherculosis with sero-fibrinous or bloody exudation.
(2) Chronic tuberculosis, characterized by larger growths, which tend to
caseate and ulcerate. The exudate is purulent or sero-purulent, and is often
sacculated.
(3) Chronic fibroid tuberculosis, which may be subacute from the onset,
or which may represent the final stage of an acute miliary eruption. The
tubercles are hard and pigmented. There is little or no exudation, and the
serous surfaces are matted together by adhesions.
The process may be primary and local, which was the case in 5 of 17
post mortems. In children the infection appears to pass from the intestines,
and in adults this is the source in the cases associated ^dth chronic phthisis.
In women the disease extends commonly from the Fallopian tubes. In at
least 30 or 40 per cent of the instances of laparotomy in this affection reported
by gjTifecologists the infection was from them. The prostate or the sem-
inal vesicles may be the starting-point. In many cases the peritonaeum is
involved with the pleura and pericardium, particularly with the former
membrane.
It is interesting to note that certain morbid conditions of the abdominal
organs predispose to the development of the disease ; thus patients with cirrho-
sis of the liver very often die of an acute tuberculous peritonitis. The fre-
quency with which the condition is met with in operations upon ovarian
tumors has been commented upon by gynaecologists. Many cases have fol-
lowed trauma of the abdomen. A very interesting feature is the occurrence
of tuberculosis in hernial sacs. The condition is not very uncommon. In a
majority of the instances it has been discovered accidentally during the oper-
ation for radical cure or for strangulation. In 7 instances the sac alone was
involved.
It is generally stated that males are attacked oftener than females, but
in the collected statistics I find the cases to be twice as numerous in females
as in males; in the ratio, indeed, of 131 to 60.
Tuberculous peritonitis occurs at all ages. It is common in children asso-
ciated with intestinal and mesenteric disease. The incidence is most fre-
quent between the ages of twenty and fort)^ It may occur in advanced life.
In one of my cases the patient was eighty-two years of age. Of 357 cases
collected by me from the literature, there were under ten years, 27 ; between
ten and twenty, 75; from twenty to tliirty, 87; between thirty and fortv, 71;
from forty to fifty, 61 ; from fifty to sixty, 19 ; from sixty to seventy, 4 ;
above seventy, 2. In America it is more common in the negro than in the
white race. More blacks than whites, 77 to 70, were admitted to the Johns
Hopkins Hospital (Hamman).
Sijmptoms.—ln certain special features the tuberculous varies consider-
TUBERCULOSIS. 311
ably from other forms of peritonitis. It presents a symptom-complex of
extraordinary diversity.
In the first place, the process may be latent and met with accidentally
in the operation for hernia or for ovarian tumor. The acute onset is not
uncommon. Four cases in our records were diagnosed appendicitis, two acute
cholecystitis, and six had symptoms of intestinal obstruction, in two of these
coming on with great abruptness (Hamman). The cases have been mistaken
for strangulated hernia. Other cases set in acutely with fever, abdominal
tenderness, and the symptoms of ordinary acute peritonitis. Cases with a
slow onset, abdominal tenderness, tympanites, and low continuous fever are
often mistaken for typhoid fever.
Ascites is frequent, but the effusion is rarely large. It is sometimes hsem-
orrhagic. In this form the diagnosis may rest between an acute miliary
cancer, cirrhosis of the liver, and a chronic simple peritonitis — conditions
which usually offer no special difficulties in differentiation. A most impor-
tant point is the simultaneous presence of a pleurisy. The tuberculin test
may be used. Tympanites may be present in the very acute cases, when it
is due to loss of tone in the intestines, owing to inflammatory infiltration; or
it may occur in the old, long-standing cases when universal adhesion has taken
place between the parietal and visceral layers. Fever is a marked symptom
in the acute cases, and the temperature may reach 103° or 104°. In many
instances the fever is slight. In the more chronic cases subnormal tempera-
tures are common, and for days the temperature may not rise above 97°, and
the morning record may be as low as 95.5°. An occasional symptom is pig-
mentation of the skin, which in some cases has led to the diagnosis of Addi-
son's disease. A striking peculiarity of tuberculous peritonitis is the fre-
quency with which the condition either simulates or is associated with tumor.
This may be :
(a) Omental, due to puckering and rolling of this membrane until it
forms an elongated firm mass, attached to the transverse colon and lying
athwart the upper part of the abdomen. This cord-like structure is found
also with cancerous peritonitis, but is much more common in tuberculosis.
Gairdner has called special attention to this form of tumor, and in children
has seen it undergo gradual resolution. A resonant percussion note may
sometimes be elicited above the mass. Though usually situated near the
umbilicus, the omental mass may form a prominent tumor in the right iliac
region.
(&) Sacculated exudation, in which the effusion is limited and confined
by adhesions between the coils, the parietal peritonasum, the mesentery, and
the abdominal or pelvic organs. This encysted exudate is most common in
the middle zone, and has frequently been mistaken for ovarian tumor. It may
occupy the entire anterior portion of the peritonaBum, or there may be a more
limited saccular exudate on one side or the other. Within the pelvis it is
associated with disease of the Fallopian tubes. Eighteen cases in the gyneco-
logical wards (J. H. H.) were operated upon for pyosalpinx (Hamman).
(c) In rare cases the tumor formations may be due to great retraction
or thickening of the intestinal coils. The small intestine is found short-
ened, the walls enormously thickened, and the entire coil may form a firm
knot close against the spine, giving on examination the idea of a solid mass.
312 SPECIFIC INFECT lOVS DISEASES.
Not the small intestine only, but the entire Ijowel from the duodenum to the
rectum, has been found forming such a hard nodular tumor.
(d) Mesenteric glands, which occasionally form very large, tumor-like
masses, more commonly foimd in children than in adults. This condition
may be confined to the abdominal glands. Ascites may coexist. The condi-
tion must be distinguished from that in children, in which, with ascites or
tjTapanites — sometimes both — there can be felt irregular nodular masses, due
to large caseous formations between the intestinal coils. 'No doubt in a con-
siderable number of cases of the so-called tabes mesenterica, particularly in
those with enlargement and hardness of the abdomen — the condition which
the French call carreau — there is involvement also of the peritonaeum.
The diagnosis of these peritoneal tumors is sometimes very difficult. The
omental mass is a less frequent source of error than any other ; but, as already
mentioned, a similar condition may occur in cancer. The most important
problem is the diagnosis of the saccular exudation from ovarian tumor. In
fully one-third of the recorded cases of laparotomy in tuberculous peritonitis,
the diagnosis of cystic ovarian disease had been made. The most suggestive
points for consideration are the history of the patient and the evidence of
old tuberculous lesions. The physical condition is not of much help, as in
many instances the patients have been robust and well nourished. Irregular
febrile attacks, gastro-intestinal disturbance, and pains are more common
in tuberculous disease. Unless inflamed there is usually not much fever with
ovarian cysts. The local signs are very deceptive, and in certain cases have
conformed in every particular to those of cystic disease. The outlines in sac-
cular exudation are rarely so well defined. The position and form may be
variable, owing to alterations in the size of the coils of which in parts the
walls are composed. Nodular cheesy masses may sometimes be felt at the
periphery. Depression of the vaginal wall is mentioned as occurring in
encysted peritonitis : but it is also found in ovarian tumor. Lastly, the con-
dition of the Fallopian tubes, of the lungs and the pleurse, should be thor-
oughly examined. The association of salpingitis with an Hi-defined anoma-
lous mass in the abdomen should arouse suspicion, as should also involvement
of the pleura, the apex of one lung, or a testis in the male.
IV. Pulmonary Tubeeculosis {Phthisis, Consumption).
Three clinical groups may be conveniently recognized: (1) tuberculo-
pneumonicplLt]iisis—AQ\\ie^\ii\Aii%; (2) chronic ulcerative pUMsis; and (3)
fibroid phthisis.
According to the mode of infection there are two distinct t}-pes of lesions :
(a) When the bacilli reach the limgs through the blood-vessels or lym-
phatics the primary lesion is usually in the tissues of the alveolar walls, in
the capillary vessels, the epithelium of the air-cells, and in the connective-
tissue framework of the septa. The irritation of the bacilli produces, within
a few days, the small, gray miliary nodules, involving several alveoli and con-
sisting largely of round, cuboidal, uninuclear epithelioid cells. Depending
upon the number of bacilli which reach the lung in this way, either a localized
or a general tuberculosis is excited. The tubercles may be uniformlv scat-
tered through both lungs and form a part of a general miliary tuberculo-
TUBERCULOSIS. 313
sis, or they may be confined to the lungs, or even in great part to one lung.
The changes which the tubercles undergo have already been referred to. The
further stages may be: (1) Arrest of the process of cell division, gradual
sclerosis of the tubercle, and ultimately complete fibroid transformation.
(2) Caseation of the centre of the tubercle, extension at the periphery by
proliferation of the epithelioid and lymphoid cells, so that the individual
tubercles or small groups become confiuent and form diffuse areas which
undergo caseation and softening. (3) Occasionally as a result of intense
infection of a localized region through the blood-vessels the tubercles are
thickly set. The intervening tissue becomes acutely inflamed, the air-cells
are filled with the products of a desquamative pneumonia, and many lobules
are involved.
(&) When the bacilli reach the lung through the bronchi — inhalation or
aspiration tuberculosis — the picture differs. The smaller bronchi and bron-
chioles are more extensively affected; the process is not confined to single
groups of alveoli, but has a more lobular arrangement, and the tuberculous
masses from the outset are larger, more diffuse, and may in some cases involve
an entire lobe or the greater part of a lung. It is in this mode of infection
that we see the characteristic peri-bronchial granulations and the areas of
the so-called nodular broncho-pneumonia. These broncho-pneumonic areas,
with on the one hand caseation, ulceration, and cavity formation, and on the
other sclerosis and limitation, make up the essential elements in the anatom-
ical picture of tuberculous phthisis.
1. Acute Pneumonic Tuberculosis of the Lungs.
This form, known also by the name of galloping consumption, is met with
both in children and adults. In the former many of the cases are mistaken
for simple broncho-pneumonia.
Two types may be recognized, the pneumonic and hroncho-pneumonic.
The Pneumonic Form. — In the pneumonic form one lobe may be involved,
or in some instances an entire lung. The organ is heavy, the affected portion
airless ; the pleura is usually covered with a thin exudate, and on section the
picture resembles closely that of ordinary hepatization. The following is an
extract from the post-mortem report of a case in which death occurred twenty-
nine days after the onset of the illness, having all the characters of an acute
pneumonia: "Left lung weighs 1,500 grammes (double the weight of the
other organ) and is heavy and airless, crepitant only at the anterior margins.
Section shows a small cavity the size of a walnut at the apex, about which
are scattered tubercles in a consolidated tissue. The greater part of the lung
presents a grayish-white appearance due to the aggregation of tubercles which
in some places have a continuous, uniform appearance, in others are sur-
rounded by an injected and consolidated lung-tissue. Toward the margins of
the lower lobe strands of this firm reddish tissue separate angemic, dry areas.
There are in the right lung three or four small groups of tubercles but no
caseous masses. The bronchial glands are not tuberculous." Here the intense
local infection was due to the small focus at the apex of the lung, probably an
aspiration process.
Only the most careful inspection may reveal the presence of miliary tuber-
cles, or the attention may be arrested by the detection of tubercles in the other
314 SPECIFIC INFECTIOUS DISEASES.
lung or in the bronchial glands. The process may involve only one lobe.
ThS-e may be older areas which are of a peculiarly yellowish-white color and
distinctly caseous. The most remarkable picture is presented by cases of this
kind in which the disease lasts for some months. A lobe or an entire lung
may be enlarged, firm, airless throughout, and converted into a dr}^, yellowish-
white, cheesy substance. Cases are met with in which the entire kmg from
apex to base is in this condition, with perhaps only a small, narrow area of
air-containing tissue on the margin. More commonly, if the case has lasted
for two or three months, rapid softening has taken place at the apex with
extensive cavity formation.
Males are much more frequently attacked than females. Of my series of
15 cases, 11 were in males. The onset was acute in 13, with a chill in 9. Ba-
cilli were found in the sputum in one case as early as the fourth day. Fraenkel
and Troje believe that the cases are of bronchogenous origin, due to infection
from a small focus somewhere in the lung. They found tubercle bacilli alone
in 11 of their 13 cases. Tendeloo reports a fatal case on the sixth day, and
regards the infection as sometimes hematogenous.
Symptoms. — The attack sets in abruptly with a chill, usually in an indi-
vidual who has enjoyed good health, although in many cases the onset has
been preceded by exposure to cold, or there have been debilitating circum-
stances. The temperature rises rapidly after the chill, there are pain in the
side, and cough, with at first mucoid, subsequently rusty-colored expectora-
tion which may contain tubercle bacilli. The dyspnoea may become extreme
and the patient may have suffocative attacks. The physical examination shows
involvement of one lobe or of one lung, with signs of consolidation, dulness, in-
creased fremitus, at first feeble or suppressed vesicular murmur, and subse-
quently well-marked bronchial breathing. The upper or lower lobe may be
involved, or in some cases the entire lung.
At this time, as a rule, no suspicion enters the mind of the practitioner
that the case is anything but one of frank lobar pneumonia. Occasionally
there may be suspicious circumstances in the history of the patient or in his
family; but, as a rule, no stress is laid upon them in view of the intense and
characteristic mode of onset. Between the eighth and tenth day, instead
of the expected crisis, the condition becomes aggravated, the temperature is
irregular, and the pulse more rapid. There may be sweating, and the expec-
toration becomes muco-purulent and greenish in color — a point of special
importance, to which Traube called attention. Even in the second or third
week, with the persistence of these symptoms, the physician tries to console
himself with the idea that the case is one of unresolved pneumonia, and that
all will yet be well. Gradually, however, the severity of the sjmptoms, the
presence of physical signs indicating softening, the existence of elastic tissue
and tubercle bacilli in the sputa present the mournful proofs that the case is
one of acute pneumonic phthisis. Death may occur on the sixth day, as in
a case of Tendeloo. The earliest death in my series was on the thirteenth day.
A majority of the cases drag on, and death does not occur until the third
month. In a few cases, even after a stormy onset and active course, the symp-
toms subside and the patient passes into the chronic stage.
Diagnosis. — Waters, of Liverpool, who gave an admirable description of
these cases, called attention to the difficulty in distinguishing them from ordi-
TUBERCULOSIS. 315
nary pneumonia. Certainly the mode of onset affords no criterion whatever.
A healthy, robust-looking young Irishman, a cab-driver, who had been kept
waiting on a cold, blustering night until three in the morning, was seized the
next afternoon with a violent chill, and the folloAving day was admitted to
my wards at the University Hospital, Philadelphia. He was made the sub-
ject of a clinical lecture on the fifth day, when there was absent no single
feature in history, symptoms, or physical signs of acute lobar pneumonia of
the right upper lobe. It was not until ten days later, when bacilli were found
in his expectoration, that we were made aware of the true nature of the case.
I know of no criterion by which cases of this kind can be distinguished in the
early stage. A point to which Traube called attention, and which is also
referred to as important by Herard and Cornil, is the absence of breath-sounds
in the consolidated region ; but this, I am sure, does not hold good in all cases.
The tubular breathing may be intense and marked as early as the fourth day;
and again, how common it is to have, as one of the earliest and most suggestive
symptoms of lobar pneumonia, suppression or enfeeblement of the vesicular
murmur ! In many cases, however, there are suspicious circumstances in the
onset: the patient has been in bad health, or may have had previous pulmo-
nary trouble, or there are recurring chills. Careful examination of the sputa
and a study of the physical signs from day to day can alone determine the
true nature of the case. In one of my cases the bacilli were found on the
fourth day. A point of some moment is the character of the fever, which
in true pneumonia is more continuous, particularly in severe cases, whereas
in this form of tuberculosis remissions of 1.5° or 2° are not infrequent.
Acute tuberculous broncho-pneumonia is more common, particularly in
children, and forms a majority of the cases of phthisis florida, or " galloping
consumption." It is an acute caseous broncho-pneumonia, starting in the
smaller tubes, which become blocked with a cheesy substance, while the air-
cells of the lobule are filled with the products of a catarrhal pneumonia. In
the early stages the areas have a grayish-red, later an opaque-white, caseous
appearance. By the fusion of contiguous masses an entire lobe may be ren-
dered nearly solid, but there can usually be seen between the groups areas of
crepitant air tissue. This is not an uncommon picture in the acute phthisis
of adults, but it is still more frequent in children. The following is an ex-
tract from the post-mortem report of a case on a child aged four months,
who died in the sixth week of illness : " On section, the right upper lobe
is occupied with caseous masses from 5 to 13 mm. in diameter, separated
from each other by an intervening tissue of a deep-red color. The bronchi are
filled with cheesy substance. The middle and lower lobes are studded with
tubercles, many of which are becoming caseous. Toward the diaphragmatic
surface of the lower lobe there is a small cavity the size of a marble. The
left lung is more crepitant and uniformly studded with tubercles of all sizes,
some as large as peas. The bronchial glands are very large, and one contains
a tuberculous abscess."
There is a form of tuberculous aspiration pneumonia, to which Baumler
has called attention, occurring as a sequence of haemoptysis, and due to the
aspiration of blood and the contents of pulmonary cavities into the finer tubes.
There are fever, dyspnoea, and signs of a diffuse broncho-pneumonia. Some
of these cases run a very rapid course, and are examples of galloping consump-
316 SPECIFIC INFECTIOUS DISEASES,
tion following liEcmoptysis. This accident may occur not only early in the
disease, but may follow haemorrhage in a well-marked pulmonary tuberculosis.
In 'children the enlarged bronchial glands usually surround the root of
the lung, and even pass deeply into the substance, and the lobules are often
involved by direct contact.
In other cases the caseous broncho-pneumonia involves groups of alveoli
or lobules in different portions of the lungs, more commonly at both apices,
forming areas from 1 to 3 cm. in diameter. The size of the mass depends
largely ''upon that of the bronchus involved. There are cases which probably
should come in this category, in which, with a history of an acute illness of
from four to eight weeks, the lungs are extensively studded with large gray
tubercles, ranging in size from 5 to 10 mm. In some instances there are
cheesy masses the size of a cherry. All of these are grayish-white in color,
distinctly cheesy, and between the adjacent ones, particularly in the lower
lobe, there may be recent pneumonia, or the condition of lung which has been
termed splenization. In a case of this kind at the Philadelphia Hospital death
took place about the eighth week from the abrupt onset of the illness with
haemorrhage. There were no extensive areas of consolidation, but the cheesy
nodules were uniformly scattered throughout both lungs. Xo softening had
taken place.
Secondary infections are not uncommon; but Prudden was able to show
that the tubercle bacillus could produce not only distinct tubercle nodules,
but also the various kinds of exudative pneumonia, the exudates varpng in
appearance in different cases, which phenomena occurred absolutely without
the intervention of other organisms. The fact that these latter had not sub-
sequently crept in was shown by cultures at the autopsy on the affected animal.
Symptoms. — The s}Tnptoms of acute broncho-pneumonic phthisis are very
variable. In adults the disease may attack persons in good health, but over-
worked or " run down "' from anj^ cause. Haemorrhage initiates the attack
in a few cases. There may be repeated chills; the temperature is high, the
pulse rapid, and the respirations are increased. The loss of flesh and strength
is very striking.
The physical signs may at first be uncertain and indefinite, but finally
there are areas of impaired resonance, usually at the apices; the breath-
sounds are harsh and tubular, with numerous rales. The sputa may early
show elastic tissue and tubercle bacilli. In the acute cases, within three weeks,
the patient may be in a marked tj-phoid state, with delirium, dry tongue, and
high fever. Death may occur within three weeks. In other cases the onset
is severe, with high fever, rapid loss of fiesh and strength, and signs of exten-
sive unilateral or bilateral disease. Softening takes place; there are sweats,
chills, and progressive emaciation, and all the features of phthisis florida.
Six or eight weeks later the patient may begin to improve, the fever lessens,
the general s^Tnptoms abate, and a case which looks as if it would certainly
terminate fatally within a few weeks drags on and becomes chronic.
In children the disease most commonly follows the infectious diseases,
particularly measles and whooping-cough.* 'The profession is gradually recog-
nizing the fact that a majority of all such cases are tuberculous. At least
■ Tussis convulsiva vestibulum tabis " (Willis).
TUBERCULOSIS. 317
three groups of these tuberculous broncho-pneumonias may be recognized. In
the first the child is taken ill suddenly while teething or during convales-
cence from fever; the temperature rises rapidly, the cough is severe, and
there may be signs of consolidation at one or both apices with rales. Death
may occur within a few days, and the lung shows areas of broncho-pneumonia,
with perhaps here and there scattered opaque grayish-yellow nodules. Macro-
scopically the affection does not look tuberculous, but histologically miliary
granulations and bacilli may be found. Tubercles are usually present in the
bronchial glands, but the appearance of the broncho-pneumonia may be ex-
ceedingly deceptive, and it may require careful microscopical examination to
determine its tuberculous character. The second group is represented by the
case of the child previously quoted, which died at the sixth week with the
ordinary symptoms of severe broncho-pneumonia. And the third group is
that in which, during the convalescence from an infectious disease, the child
is taken ill with fever, cough, and shortness of breath. The severity of the
symptoms abates within the first fortnight ; but there is loss of flesh, the gen-
eral condition is bad, and the physical examination shows the presence of
scattered rales throughout the lungs, and here and there areas of defective
resonance. The child has sweats, the fever becomes hectic in character, and
in many cases the clinical picture gradually passes into that of chronic
phthisis.
2. Chronic Ulcerative Tuberculosis of the Lungs.
Under this heading may be grouped the great majority of cases of pul-
monary tuberculosis, in which the lesions proceed to ulceration and softening,
and ultimately produce the well-known picture of chronic phthisis. At first
a strictly tuberculous affection, it ultimately becomes, in a majority of cases,
a mixed disease, many of the most prominent symptoms of which are due to
septic infection from purulent foci and cavities.
Morbid Anatomy. — Inspection of the lungs in a case of chronic phthisis
shows a remarkable variety of lesions, comprising nodular tubercles, diffuse
tuberculous infiltration, caseous masses, pneumonic areas, cavities of various
sizes, with changes in the pleura, bronchi, and bronchial glands.
1. The Distribution op the Lesions. — For years it has been recognized
that the most advanced lesions are at the apices, and that the disease pro-
gresses downward, usually more rapidly in one of the lungs. This general
statement, which has passed current in the text-books ever since the masterly
description of Laennec, has been carefully elaborated by Kingston Fowler,
who finds that the disease in its onward progress through the lungs follows,
in a majority of the cases, distinct routes. In the upper lobe the primary
lesion is not, as a rule, at the extreme apex, but from an inch to an inch and
a half below the summit of the lung, and nearer to the posterior and external
borders. The lesion here tends to spread downward, probably from inhala-
tion of the virus, and this accounts for the frequent circumstance that exami-
nation behind, in the supra-spinous fossa, will give indications of disease before
any evidences exist at the apex in front. Anteriorly this initial focus corre-
sponds to a spot Just below the centre of the clavicle, and the direction of
extension in front is along the anterior aspect of the upper lobe, along a line
running about an inch and a half from the inner ends of the first, second,
3^3 SPECIFIC INFECTIOUS DISEASES.
and third interspaces. A second less common site of the primary lesion in
the apex " corresponds on the chest wall with the first and second interspaces
below the outer third of the clavicle." The extension is doT\Tiward, so that
the outer part of the upper lobe is chiefly involved.
In the middle lobe of the right lung the affection usually follows disease
of the upper lobe on the same side. In the involvement of the lower lobe
the first secondary infiltration is about an inch to an inch and a half below
the posterior extremity of its apex, and corresponds on the chest wall to a
spot opposite the fifth dorsal spine. This involvement is of the greatest im-
portance clinically, as " in the great majority of cases, when the physical signs
of the disease at the apex are sufficiently definite to allow of the diagnosis of
phthisis being made, the lower lobe is already affected.'' Examination, there-
fore, should be made carefully of this posterior apex in all suspicious cases.
In this situation the lesion spreads downward and laterally along the line
of the interlobular septa, a line which is marked by the vertebral border
of the scapula, when the hand is placed on the opposite scapula and the
elbow raised above the level of the shoulder. Once present in an apex, the
disease usually extends in time to the opposite upper lobe; but not, as a
rule, until the apex of the lower lobe of the lung first affected has been
attacked.
Of 427 cases above mentioned, the right apex was involved in 172, the
left in 130, both in 11].
Lesions of the base may be primary, though this is rare. Percy Kidd
makes the proportion of basic to apical phthisis 1 to 500, a smaller number
than existed in my series. In very chronic cases there may be arrested lesions
at the apex and more recent lesions at the base.
2. Summary of the Lesioivts in CHEOisric Ulceeative Phthisis. —
(a) Miliary Tubercles. — They have one of two distributions: (1) A dissemi-
nation due to aspiration of tuberculous material, the tubercles being situated
in the air-cells or the walls of the smaller bronchi; (2) the distribution due
to dissemination of tubercle bacilli by the IjTnph current, the tubercles being
scattered about the old foci in a radial manner — ^the secondary crop of Laen-
nec. Much more rarely there is a scattered dissemination from infection here
and there of the smaller vessels, the tubercles then being situated in the vessel
walls. Sometimes, in cases with cavity formation at the apex, the greater
part of the lower lobes presents many groups of firm, sclerotic, miliary tuber-
cles, which may indeed form the distinguishing anatomical feature — a chronic
miliary tuberculosis.
(6) Tuberculous Bronclio-pneumonia. — In a large proportion of the cases
of chronic phthisis the terminal bronchiole is the point of origin of the process,
consequently we find the smaller bronchi and their alveolar territories blocked
with the accumulated products of inflammation in all stages of caseation.
At an early period a cross-section of an area of tuberculous broncho-pneumonia
gives the most characteristic appearance. The central bronchiole is seen as
a small orifice, or it is plugged with cheesy contents, while surrounding it is
a caseous nodule, the so-called peribronchial tubercle. The longitudinal sec-
tion has a somewhat dendritic or foliaceous appearance. The condition of the
picture depends much upon the slowness or rapidity with which the process
has advanced. The following changes may occur:
TUBERCULOSIS. 319
Ulceration. — When the caseation takes place rapidly or ulceration occurs
i'n the bronchial wall, the mass may break down and form a small cavity.
Sclerosis. — In other instances the process is more chronic, and fibroid
changes gradually produce a sclerosis of the affected area. The sclerosis may
be confined to the margin of the mass, forming a limiting capsule, within
which is a uniform, firm, cheesy substance, in which lime salts are often
deposited. This represents the healing of one of these areas of caseous
broncho-pneumonia. It is only, however, when complete fibroid transforma-
tion or calcification has occurred that we can really speak of healing. In
many instances the colonies of miliary tubercles about these masses show
that the virus is still active in them. Subsequently, in ulcerative processes,
these calcareous bodies — lung-stones, as they are sometimes called — may be
expectorated.
(c) Pneumonia. — An important though secondary place is occupied by
inflammation of the alveoli surrounding the tubercles, which become filled with
epithelioid cells. The consolidation may extend for some distance about
the tuberculous foci and unite them into areas of uniform consolidation.
Although in some instances this inflammatory process may be simple, in
others it is undoubtedly specific. It is excited by the tubercle bacilli and is
a manifestation of their action. It may present a very varied appearance;
in some instances resembling closely ordinary red hepatization, in others
being more homogeneous and infiltrated, the so-called infiltration tuberculeuse
of Laennec. In other cases the contents of the alveoli undergo fatty degen-
eration, and appear on the cut surface as opaque white or yellowish-white
bodies. In early phthisis much of the consolidation is due to this pneumonic
infiltration, which may surround for some distance the smaller tuberculous
foci.
{d) Cavities. — A vomica is a cavity in the lung tissue, produced by necro-
sis and ulceration. The process usually begins in the wall of the bronchus in
a tuberculous area. Dilatation is produced by retained secretion, and necrosis
and ulceration of the wall occur with gradual destruction of the contiguous
tissues. By extension of the necrosis and ulceration the cavity increases, con-
tiguous ones unite, and in an affected region there may be a series of small
excavations communicating with a bronchus. In nearly all instances the pro-
cess extends from the bronchi, though it is possible for necrosis and softening
to take place in the centre of a caseous area without primary involvement of
the bronchial wall. Three forms of cavities may be recognized.
The fresh ulcerative, seen in acute phthisis, in which there is no limiting
membrane, but the walls are made up of softened, necrotic, and caseous
masses. A small vomica of this sort, situated just beneath the pleura, may
rupture and cause pneumothorax. In cases of acute tuberculo-pneumonic
phthisis they may be large, occupying the greater portion of the upper lobe.
In the chronic ulcerative phthisis, cavities of this sort are invariably present
in those portions of the lung in which the disease is advancing. At the
apex there may be a large old cavity with well-defined walls, while at the
anterior margin of the upper lobes, or in the apices of the lower lobes, there
are recent ulcerating cavities communicating with the bronchi.
Cavities with Well-defined Walls. — A majority of the cavities in the
chronic form of phthisis have a well-defined limiting membrane, the inner
320 SPECIFIC INFECTIOUS DISEASES.
surface of which constantly produces pus. The walls are crossed by trabec-
ulse wliich represent remnants of bronchi and blood-vessels. Even the vomicas
with the well-defined walls extend gradually by a slow necrosis and destruc-
tion of the contiguous lung tissue. The contents are usually purulent, sim-
ilar in character to the gra3dsh nummular sputa coughed up by phthisical
patients. Not infrequently the membrane is vascular or it may be haemor-
rhagic. Occasionally, when gangrene has occurred in the wall, the contents
are\orribly foetid. These cavities may occupy the greater portion of the
apex, forming an irregular series which communicate with each other and
with' the bronchi, or the entire upper lobe except the anterior margin may
be excavated, forming a thin-walled cavity. In rare instances the process has
proceeded to total excavation of the lung, not a remnant of which remains,
except perhaps a narrow strip at the anterior margin. In a case of this kind,
in a young girl, the cavity held 40 fluid ounces, in another 43 ounces.
Quiescent Cavities. — When quite small and surrounded by dense cicatricial
tissue communicating with the bronchi they form the cicatrices fistuleuses of
Laennec. Occasionally one apex may be represented by a series of these small
cavities, surrounded by dense fibrous tissue. The lining membrane of these
old cavities may be quite smooth, almost like a mucous membrane. Cavities
of any size do not heal completely.
Cases are often seen in which it has been supposed that a cavity has healed ;
but the signs of excavation are notoriously uncertain, and there may be pec-
toriloquy and cavernous sounds with gurgling resonant rales in an area of
consolidation close to a large bronchus.
In the formation of vomica the blood-vessels gradually become closed by
an obliterating inflammation. They are the last structures to yield and may
be completely exposed in a cavity, even when the circulation is still going on
in them. Unfortunately, the erosion of a large vessel which has not yet been
obliterated is by no means infrequent, and causes profuse and often fatal haem-
orrhage. Another common event is the formation of aneurisms on the arte-
ries running in the walls of cavities. These may be small, bunch-like dilata-
tions, or they may form sacs the size of a walnut or even larger. Rasmussen,
Douglas Powell, and others have called attention to their importance in haem-
optysis, under which section they are dealt with more fully.
And, finally, about cavities of all sorts, the connective tissue grows, tend-
ing to limit their extent. The thickening is particularly marked beneath the
pleura, and in chronic cases an entire apex may be converted into a mass of
fibrous tissue, enclosing a few small cavities.
(e) Pleura. — Practically, in all cases of chronic phthisis the pleura is in-
volved. Adhesions take place which may be thin and readily torn, or dense
and firm, uniting layers of from 2 to 5 mm. in thickness. This pleurisy may
be simple, but in many cases it is tuberculous, and miliary tubercles or case-
ous masses are seen in the thickened membrane. Effusion is not at all infre-
quent, either serous, purulent, or hfemorrhagic. Pneumothorax is a common
accident.
(/) Changes in the smaller Ironclii control the situation in the early stages
of tuberculous phthisis, and play an important role throughout the disease.
The process very often begms m the walls of the smaller tubes and leads to
caseation, distention with products of inflammation, and broncho-pneumonia
TUBERCULOSIS. 321
of the lobules. In many cases the visible implication of the bronchus is an
extension upward of a process which has begun in the smallest bronchiole.
This involvement weakens the wall, leading to bronchiectasis, not an uncom-
mon event in phthisis. The mucous membrane of the larger bronchi, which is
usually involved in a chronic catarrh, is more or less swollen, and in some
instances ulcerated. Besides these specific lesions, they may be the seat, espe-
cially in children, of inflammation due to secondary invasion, most frequently
by the micrococcus lanceolatus, with the production of a broncho-pneumonia.
(g) The bronchial glands, in the more acute cases, are swollen and
oedematous. Miliary tubercles and caseous foci are usually present. In cases
of chronic phthisis the caseous areas are common, calcification may occur,
and not infrequently purulent softening.
(h) Changes in the other Organs. — Of these, tuberculosis is the most com-
mon. In my series of autopsies the brain presented tuberculous lesions in 31,
the spleen in 33, the liver in 12, the kidneys in 32, the intestines in 65, and
the pericardium in 7. Other groups of lymphatic glands besides the bron-
chial may be affected.
Amyloid change is frequent in the liver, spleen, kidneys, and mucous mem-
brane of the intestines. The liver is often the seat of extensive fatty infiltra-
tion, which may cause marked enlargement. The intestinal tuberculosis
occurs in advanced cases and is responsible in great part for the troublesome
diarrhoea.
Endocarditis is not very uncommon, and was present in 12 of my post
mortems and in 27 of Percy Kidd's 500 cases. Tubercle bacilli have been
found in the vegetations. Tubercles may be present on the endocardium,,
particularly of the right ventricle.
The larynx is frequently involved, and ulceration of the vocal cords and
destruction of the epiglottis are not at all uncommon.
Modes of Onset. — We have already seen that tuberculosis of the lungs
may occur as the chief part of a general infection, or may set in with symp-
toms which closely simulate acute pneumonia. In the ordinary type of pul-
monary tuberculosis the invasion is gradual and less striking, but presents
an extraordinarily diverse picture, so that the practitioner is often led into
error. Among the most characteristic modes of onset are the following :
(a) Latent Types. — It is probable that many slight, ill-defined ailments
are due to a local unrecognized tuberculosis of the lung. In the history of
cases. of phthisis such attacks are not infrequently mentioned.
The disease makes considerable progress before there are serious symp-
toms to arouse the attention of the patient. In workingmen the disease may
even advance to excavation of an apex before they seek advice. It is not a
little remarkable how slight the lung symptoms may have been.
The symptoms may be masked by the existence of serious disease in other
organs, as in the peritonaeum, intestines, or bones.
(b) With Symptoms of Dyspepsia and Ancemia. — The gastric mode of
onset is very common, and the early manifestations may be great irritability
of the stomach with vomiting or a type of acid dyspepsia with eructations.
In young girls (and in children) with this dyspepsia there is very frequently
a pronounced chloro-ansemia, and the patient complains of palpitation of the
heart, increasing weakness, slight afternoon fever, and amenorrhoea.
22
322 SPECIFIC INFECTIOUS DISEASES.
(c) In a considerable number of cases the onset of pulmonaiT tiTljercnlo-
sis is with symptoms which suggest malarial fever. The patient has repeated
paroxysms of chills, fevers, and sweats, which may recur with great regular-
ity. In districts in which intermittents prevail there is no more common
m'^istake than to confound the initial rigors of pulmonary tuberculosis with
malaria.
(d) Onset with Pleurisy. — The first symptoms may be a dry pleurisy over
an apex, with persistent friction murmur. In other instances the pulmonary
sjTuptoms have followed an attack of pleurisy with effusion. The exudate
gradually disappears, but the cough persists and the patient becomes fever-
ish, and gradually signs of disease at one apex become manifest. About one-
third of all cases of pleurisy with effusion subsequently have pulmonary
tuberculosis.
(e) With Laryngeal Symptoms. — The primary localization may be in the
lar}Tix, though in a majority of the instances in which huskiness and larjoi-
geal symptoms are the first noticeable features of the disease there are doubt-
less foci already existing in the lung. The group of cases in which for many
months throat and lar}Tix s3^nptoms precede the graver manifestations of pul-
monary phthisis is a very important one.
(/) Onset with Haemoptysis. — Frequently the very first s}anptom of the
disease is a brisk haemorrhage from the lungs, following which the pulmonary
symptoms may come on with great rapidity. In other cases the hasmoptysis
recurs, and it may be months before the sjTaptoms become well established.
In a majority of these cases the local tuberculous lesion exists at the date of
the haemoptysis.
(g) With Tuberculosis of the Cervico-axiUary Glands. — Preceding the
onset of pulmonary phthisis for months, or even for years, the Ijanph-glands
of the neck or of the neck and axilla of one side may be enlarged. These cases
are by no means infrequent, and they are of importance because of the latency
of the pulmonary lesions, l^owadays, when operative interference is so com-
mon, it is well to bear in mind that in such patients the corresponding apex of
the lung may be extensively involved.
(h) And, lastl}^ in by far the largest number of all cases the onset is with
a bronchitis, or, as the patient expresses it, a neglected cold. There has been,
perhaps, a liability to catch cold easily or the patient has been subject to naso-
pharjmgeal catarrh; then, following some unusual exposure, a cough begins,
which may be frequent and very irritating. The examination of the lungs
may reveal localized moist sounds at one apex and perhaps wheezing bronchitic
rales in other parts. In a few cases the early s3Tnptoms are often suggestive
of asthma with marked wheezing and diffuse piping rales.
Symptoms. — In discussing the symptoms it is usual to divide the disease
into three periods : the first embracing the time of the growth and develop-
ment of the tubercles; the second, when they soften; and the third, when
there is a formation of cavities. Unfortunately, these anatomical stages
can not be satisfactorily correlated with corresponding clinical periods, and
we often find that a patient in the third stage with a well-marked cavity is in
a far better condition and has greater prospects of recovery than a patient in
the first stage with diffuse consolidation. It is therefore better perhaps to
disregard them altogether.
TUBERCULOSIS. 323
1. Local Symptoms. — Pain in the chest may be early and troublesome
or absent throughout. It is usually associated with pleurisy, and may be
sharp and stabbing in character, and either constant or felt only during cough-
ing. Perhaps the commonest situation is in the lower thoracic zone, though
in some instances it is beneath the scapula or referred to the apex. The
attacks may recur at long intervals. Intercostal neuralgia occasionally occurs
in the course of ordinary phthisis.
Cough is one of the earliest sjnnptoms, and is present in the majority of
cases from beginning to end. There is nothing peculiar or distinctive about
it. At first dry and hacking, and perhaps scarcely exciting the attention of
the patient, it subsequently becomes looser, more constant, and associated with
a glairy, muco-purulent expectoration. In the early stages of the disease the
cough is bronchial in its origin. When cavities have formed it becomes more
paroxysmal, and is most marked in the morning or after a sleep. Cough is
not a constant symptom, however, and a patient may present himself with
well-marked excavation at one apex who will declare that he has had little or no
cough. So, too, there may be well-marked physical signs, dulness and moist
sounds, without either expectoration or cough. In well-established cases the
nocturnal paroxysms are most distressing and prevent sleep. The cough may
be of such persistence and severity as to cause vomiting, and the patient
becomes rapidly emaciated from loss of food — Morton's cough (Phthisiologia,
1689, p. 101). The laryngeal complications give a peculiarly husky quality
to the cough, and when erosion and ulceration have proceeded far in the vocal
cords the coughing becomes much less effective.
Sputum. — This varies greatly in amount and character at the different
stages of ordinary phthisis. There are cases with well-marked local signs
at one apex, with slight cough and moderately high fever, without from day
to day a trace of expectoration. So, also, there are instances with the most
extensive consolidation (caseous pneumonia), and high fever, but without
enough expectoration to enable an examination for bacilli to be made. In the
early stage of pulmonary tuberculosis the sputum is chiefly catarrhal and has
a glairy, sago-like appearance, due to the presence of alveolar cells which have
undergone the myeline degeneration. There is nothing distinctive or peculiar
in this form of expectoration, which may persist for months without indicat-
ing serious trouble. The earliest trace of characteristic sputum may show the
presence of small grayish or greenish-gray purulent masses. These, when
coughed up, are always suggestive and should be the portions picked out
for microscopical examination. As softening comes on, the expectoration
becomes more profuse and purulent, but may still contain a considerable
quantity of alveolar epithelium. Finally, when cavities exist, the sputa
assume the so-called nummular form; each mass is isolated, flattened,
greenish-gray in color, quite airless, and, when spat into water, sinks to
the bottom.
By the microscopical examination of the sputum we determine whether
the process is tuberculous, and whether softening has occurred. For tubercle
hacilli the Ehrlich-Weigert method is the best. The bacilli are seen as elon-
gated, slightly curved, red rods, sometimes presenting a beaded appearance.
They are frequently in groups of three or four, but the number varies consid-
erably. Only one or two may be found in a preparation, or, in some instances.
324 SPECIFIC INFECTIOUS DISEASES.
they are so abundant that the entire field is occupied. Eepeated examinations
may be necessary.
The continued presence of tubercle bacilli in the sputum is an infallible in-
dication of the existence of tuberculosis.
One or two may possibly be due to accidental inhalation. A number may
come from a spot of softening 3 by 3 cm. In the nummular sputa of later
stages the bacilli are very abundant.
Elastic tissue may be derived from the bronchi, the alveoli, or from the
arterial coats ; and naturally the appearance of the tissue will vary with the
locality from which it comes. In the examination for this it is not necessary
to boil the sputum with caustic potash. For years I have used a simple plan
which was shown to me at the London Hospital by Sir Andrew Clark. This
method depends upon the fact that in almost all instances if the sputum is
spread in a sufficiently thin layer the fragments of elastic tissue can be seen
with the naked eye. The thick, purulent portions are placed upon a glass
plate 15 X 15 cm. and flattened into a thin layer by a second glass plate
10 X 10 cm. In this compressed grayish layer between the glass slips any
fragments of elastic tissue show on a black background as grayish-yellow
spots and can either be examined at once under a low power or the uppermost
piece of glass is slid along until the fragment is exposed, when it is picked
out and placed upon the ordinary microscopic slide. Fragments of bread
and collections of milk-globules may also present an opaque white appearance,
but with a little practice they can readily be recognized. Fragments of epi-
thelium from the tongue, infiltrated with micrococci, are still more deceptive,
but the microscope at once shows the difference.
The bronchial elastic tissue forms an elongated network, or two or three
long, narrow fibres are found close together. From the blood-vessels a some-
what similar form may be seen and occasionalh'' a distinct sheeting is found
as if it had come from the intima of a good-sized artery. The elastic tissue
of the alveolar wall is quite distinctive; the fibres are branched and often
show the outline of the arrangement of the air-cells. The elastic tissue from
bronchi or alveoli indicates extensive erosion of a tube and softening of the
lung-tissue.
Another occasional constituent of the sputum is blood, which may be pres-
ent as the chief characteristic of the expectoration in haemoptysis or may
simply tinge the sputum. In chronic cases with large cavities, in addition to
bacteria, various forms of fungi may be found, of which the aspergillus is the
most important. Sarcinge may also occur.
Calcareous Fragments. — Formerly a good deal of stress was laid upon their
presence in the sputum, and Morton described a phthisis a calculis in pulmoni-
bus generatis. Bayle also described a separate form of phthisie calculeuse.
The size of the fragments varies from a small pea to a large cherry.
As a rule, a single one is ejected; sometimes large numbers are coughed
up in the course of the disease. They are formed in the lung by the calcifica-
tion of caseous masses, and it is said also occasionally in obstructed bronchi.
They may come from the bronchial glands by ulceration into the bronchi, and
there is a case on record of suffocation in a child from this cause.
The daily amount of expectoration varies. In rapidly advancing cases,
with much cough, it may reach as high as 500 cc. in the day. In cases with
TUBERCULOSIS. 325
large cavities the chief amount is brought up in the morning. The expectora-
tion of tuberculous j)atients usually has a heavy, sweetish odor, and occasion-
ally it is fetid, owing to decomposition in the cavities.
HEMOPTYSIS. — One of the most famous of the Hippocratic axioms says,
" From a spitting of blood there is a spitting of pus," The older writers
thought that the phthisis was directly due to the inflammatory or putrefactive
changes caused by the haemorrhage into the lung. Morton, however, in his
interesting section. Phthisis ah HcBmoptoe, rather doubted this sequence.
Laennec and Louis^ and later in the century Traube, regarded the hgemoptysis
as an evidence of existing disease of the lung. From the accurate views of
Laennec and Louis the profession was led away by Graves, and particularly by
Niemeyer, who held that the blood in the air-cells set up an inflammatory
process, a common termination of which was caseation. Since Koch's dis-
covery we have learned that many cases in which the physical examination is
negative show, either during the period of haemorrhage or immediately after it,
tubercle bacilli in the sputa, so that opinion has veered to the older view,
and we now regard the appearance of haemoptysis as an indication of existing
disease. In young, apparently healthy persons, cases of haemoptysis may be
divided into three groups. In the first the bleeding has come on without
premonition, without overexertion or injury, and there is no family history of
tuberculosis. The physical examination is negative, and the examination of
the expectoration at the time of the haemorrhage and subsequently shows no
tubercle bacilli. Such instances are not uncommon, and, though one may
suspect strongly the presence of some focus of tuberculosis, yet the individuals
may retain good health for many years, and have no further trouble. Of the
386 cases of haemoptysis noted by Ware in private practice, 62 recovered, and
pulmonary disease did not subsequently occur.
In a second group individuals in apparently perfect health are suddenly
attacked, perhaps after a slight exertion or during some athletic exercises.
The physical examination is also negative, but tubercle bacilli are found some-
times in the bloody sputa, more frequently a few days later.
In a third set of cases the individuals have been in failing health for a
month or two, but the symptoms have not been urgent and perhaps not noticed
by the patients. The physical examination shows the presence of well-marked
tuberculous disease, and there are both tubercle bacilli and elastic tissue in the
sputa.
A very interesting systematic study of the subject of haemoptysis, particu-
larly in its relation to the question of tuberculosis, has been completed in the
Prussian army by Franz Strieker. During the five years 1890-95 there were
900 cases admitted to the hospitals, which is a percentage of 0.045 of the
strength (1,728,505). Of the cases, in 480 the haemorrhage came on with-
out recognizable cause. Of these, 417 cases, 86 per cent, were certainly or
probably tuberculous. In only 221, however, was the evidence conclusive.
In a second group of 213 cases the haemorrhage came on during the mili-
tary exercise, and of these 75 patients were shown to be tuberculous.
In 118 cases the hemorrhage followed certain special exercises, as in the
gymnasium or in riding or in consequence of swimming. In 24 cases it
occurred during the exercise of the voice in singing or in giving command or in
the use of wind instruments. A very interesting group is reported of 24 cases
326 SPECIFIC INFECTIOUS DISEASES.
in which the haBmorrhage followed trauma, either a fall or a blow upon the
thorax. In 7 of these tuberculosis was positively present, and in 6 other
cases there was a strong probability of its existence.
Among the conclusions which Strieker draws the following are the most
important: namely, that soldiers attacked with hsemoptysis without special
cause are in at least 86.8 per cent tuberculous. In the cases in which the
ha3mopt3^sis follows the special exercises, etc., of military service, at least 74.4
per cent are tuberculous. In the cases which come on during swimming or
as a consequence of direct injury to the thorax about one-half are not associ-
ated with tuberculosis.
Haemoptysis occurs in from 60 to 80 per cent of all cases of pulmonary
tuberculosis. It is more frequent in males than in females.
In a majority of all eases the bleeding recurs. Sometimes it is a special
feature throughout the disease, so that a hsemorrhagic form has been recog-
nized. The amount of blood brought up varies from a couple of drachms to
a pint or more. In 69 per cent of 4,125 cases of hgemoptysis at the Brompton
Hospital the amount brought up was under half an ounce.
A distinction may be drawn between the haemoptysis early in the disease
and that which occurs in the later periods. In the former the bleeding is
usually slight, is apt to recur, and fatal haemorrhage is very rare. In these
cases the bleeding is usually from small areas of softening or from early
erosions in the bronchial mucosa. In the later periods, after cavities have
formed, the bleeding is, as a rule, more profuse and is more apt to be fatal.
Single large haemorrhages, proving quickly fatal, are very rare, except in the
advanced stages of the disease. In these cases the bleeding comes either from
an erosion of a good-sized vessel in the wall of a cavity or from the rupture
of an aneurism of the pulmonary artery.
The bleeding, as a rule, sets in suddenly. Without any warning the patient
may notice a warm salt taste and the mouth fills with blood. It may come
up with a slight cough. The total amoimt may not be more than a few
drachms, and for a day or two the patient may spit up small quantities. When
a large vessel is eroded or an aneurism bursts, the amount of blood brought
up is large, and in the course of a short time a pint or two may be expec-
torated. Fatal haemorrhage may occur into a very large cavity without any
blood being coughed up. The character of the blood is, as a rule, distinctive.
It is frothy, mixed with mucus, generally bright red in color, except when
large amounts are expectorated, and then it may be dark. The sputum may
remain blood-tinged for some days, or there are brownish-black streaks in it,
or friable nodules consisting entirely of blood-corpuscles may be coughed up.
Blood moulds of the smaller bronchi are sometimes expectorated.
The microscopical examination of the sputum in tuberculous cases is most
important. If carefully spread out, there may be noted, even in an apparently
pure hemorrhagic mass, little portions of mucus from which bacilli or elastic
tissue may be obtained.
Dyspnoea is not a common accompaniment of ordinary phthisis. The
greater part of one lung may be diseased and local trouble exist at the other
apex without any shortness of breath. Even in the paroxysms of very high
fever the respirations may not be much increased. Dyspnoea occurs (1) with
the rapid extension in both lungs of a broncho-pneumonia; (2) with the
TUBERCULOSIS. 327
occurrence of miliary tuberculosis; (3) sometimes with pneumothorax; (4)
in old cases with much emphysema, and it may be associated with cyanosis;
(5) and, lastly, in long-standing cases, with contracted apices or great thicken-
ing of the pleura, the right heart is enlarged, and the dyspnoea may be cardiac.
3. General Symptoms. — Fever. — To get a correct idea of the tempera-
ture range in pulmonary tuberculosis it is necessary, as Ringer pointed out,
to make tolerably frequent observations. The usual 8 a. ^. and 8 p. m. record
is, in a majority of the cases, very deceptive, giving neither the minimum ilor
maximum. The former usually occurs between 3 and 6 a. m., and the latter
between 3 and 6 p. m.
A recognition of various forms of fever, viz., of tuberculization, of ulcera-
tion, and of absorption, emphasizes the anatomical stages of growth, soften-
ing and cavity formation ; but practically such a division is of little use, as in
a majority of cases these processes are going on together.
Fever is the most important initial symptom and throughout the entire
course the thermometer is the most trustworthy guide as to the progress of the
affection. With pyrexia a patient loses in weight and strength, and the local
disease usually progresses. The periods of apyrexia are those of gain in weight
and strength and of limitation of the local lesion. It by no means necessarily
follows that a patient with tuberculosis has pyrexia. There may be quite
extensive disease without coexisting fever. On one occasion I had 18 instances
of chronic phthisis under observation, of whom 10 were practically free from
fever. But in the early stage, when tubercles are developing and caseous areas
are in process of formation and when softening is in progress, fever is a con-
stant symptom. There are a few rare cases in which little or no fever is
present at the outset even with advancing lesions.
Two types of fever are seen — the remittent and the intermittent. These
may occur indifferently in the early or in the late stages of the disease or
may alternate with each other, a variability which depends upon the fact
that phthisis is a progressive disease and that all stages of lesions may be
found in a single lung. Special stress should be laid upon the fact, particu-
larly in malarial regions, that tuberculosis ma}'' set in with a fever typically
intermittent in character — a daily chill, with subsequent fever and sweat.
In Montreal, where malaria is practically unknown, this was always regarded
as a suggestive symptom; but in Philadelphia and Baltimore, where ague
prevails, many cases of early tuberculosis are treated for ague. These are
often cases that pursue a rapid course. The fever of onset — tuberculization
— ^may be almost continuous, "with slight daily exacerbations ; and at any time
during the course of chronic phthisis, if there is rapid extension, the remis-
sions become less marked.
A remittent fever, in which the temperature is constantly above normal
but drops two or three degrees toward morning, is not uncommon in the
middle and later stages and is usually associated with softening or extension
of the disease. Here, too, a simple morning and evening register may give
an entirely erroneous idea as to the range of the fever. With breaking down
of the lung-tissue and formation of cavities, associated as these processes
always are with suppuration and with more or less systemic contamination,
the fever assumes a characteristically intermittent or hectic type. For a large
part of the day the patient is not only afebrile, but the temperature is sub-
328
SPECIFIC INFECTIOUS DISEASES.
normal. In the annexed two-hourly chart, from a case of chronic tuberculosis
of the lungs, it will be seen that from 10 p. m. to 8 a. m. or noon, the tem-
perature continuously fell and went as low as 95°. A slow rise then took
place through the late morning and early afternoon hours and reached its
maximum between 6 and 10 p. m. As shown in the chart, there were in the
Chart XII. — Three Days. Chronic Tuberculosis.
three days about forty-three hours of p}Texia and twenty-nine hours of apy-
rexia. The rapid fall of the temperature in the early morning hours is usually
associated with sweating. This hectic, as it is called, which is a t}^ical fever
of septic infection, is met with when the process of cavity formation and
softening is advanced and extending.
A continuous fever with remissions of not more than a degree, occurring
in the course of pulmonary tuberculosis, is suggestive of acute pneumonia.
When a two-hourly chart is made, the remissions even in acute tuberculous
pneumonia are usually well marked. A continued fever, such as is seen in
the first week of typhoid, or in some cases of inflammation of the lung, is
rare in tuberculosis.
Sweating. — Drenching perspirations are common in phthisis and consti-
tute one of the most distressing features of the disease. They occur usually
TUBERCULOSIS. 329
with the drop in the fever in the early morning hours, or at any time in the
day when the patient sleeps. They may come on early in the disease, but are
more persistent and frequent after cavities have formed. Some patients escape
altogether.
The pulse is increased in frequency, especially when the fever is high. It
is often remarkably full, though soft and compressible. Pulsation may some-
times be seen in the capillaries and in the veins on the back of the hand.
Emaciation is a pronounced feature, from which the two common names
of the disease have been derived. The loss of weight is gradual but, if the
disease is extending, progressive. The scales give one of the best indications
of the progress of the case.
3. Physical Signs. — (a) Inspection. — The shape of the chest is often
suggestive, though it is to be remembered that the disease may be met with
in chests of any build. Practically, however, in a considerable proportion
of cases the thorax is long and narrow, with very wide intercostal spaces, the
ribs more vertical in direction and the costal angle very narrow. The scap-
ulae are "^^ winged," a point noted by Hippocrates. Another type of chest
which is very common is that which is flattened in the antero-posterior diam-
eter. The costal cartilages may be prominent and the sternum depressed.
Occasionally the lower sternum forms a deep concavity, the so-called funnel
breast (TricJiter-Brust) . Inspection gives valuable information in all stages
of the disease. Special examination should be made of the clavicular regions
to see if one clavicle stands out more distinctly than the other, or if the spaces
above or below it are more marked. Defective expansion at one apex is an
early and important sign. The condition of expansion of the lower zone of
the thorax may be well estimated by inspection. The condition of the prge-
cordia should also be noted, as a wide area of impulse, particularly in the
second, third, and fourth interspaces, often results from disease of the left
apex. From a point behind the patient, looking over the shoulders, one can
often better estimate the relative expansion of the apices.
(h) Palpation. — Deficiency in expansion at the apices or bases is perhaps
best gauged by placing the hands in the subclavicular spaces and then in the
lateral regions of the chest and asking the patient to draw slowly a full breath.
Standing behind the patient and placing the thumbs in the supraclavicular
and the fingers in the infraclavicular spaces one can judge accurately as to
the relative mobility of the two sides. Disease at an apex, though early and
before dulness is at all marked, may be indicated by deficient expansion. On
asking the patient to count, the tactile fremitus is increased wherever there is
local growth of tubercle or extensive caseation. In comparing the apices it
is important to bear in mind that normally the fremitus is stronger over the
right than the left. So too at the base, when there is consolidation of the
lung, the fremitus is increased; whereas, if there is pleural effusion, it is
diminished or absent. In the later stages, when cavities form, the tactile
fremitus is usually much exaggerated over them. When the pleura is greatly
thickened the fremitus may be somewhat diminished.
(c) Percussion. — Tubercles, inflammatory products, fibroid changes, and
cavities produce important changes in the pulmonary resonance. There may
be localized disease, even of some extent, without inducing much alteration,
as when the tubercles are scattered there is air-containing tissue between
23
330 SPECIFIC INFECTIOUS DISEASES.
them. One of the earliest and most valuable signs is defective resonance
upon and above a clavicle. In a considerable proportion of all cases of phthi-
sis the dulness is first noted in these regions. The comparison between the
two sides should be made also Avhen the breath is held after a full inspiration,
as the defective resonance may then be more clearly marked. In the early
stages the percussion note is usually higher in pitch, and it may require an
experienced ear to detect the difference. In recent consolidation from case-
ous pneumonia the percussion note often has a tubular or tympanitic quality.
A wooden dulness is rarely heard except in old cases with extensive fibroid
change at the apex or base. Over large, thin-walled cavities at the apex the
so-called cracked-pot sound may be obtained. In thin subjects the percus-
sion should be carefully practised in the supraspinous fossae and the inter-
scapular space, as they correspond to very important areas early involved in
the disease. In cases with numerous isolated cavities at the apex, without
much fibroid tissue or thickening of the pleura, the percussion note may show
little change, and the contrast between the signs obtained on auscultation and
percussion is most marked. In the direct percussion of the chest, particularly
in thin patients over the pectorals, one frequently sees the phenomenon known
as myoidcema, a local contraction of the muscle causing bulging, which per-
sists for a variable period and gradually subsides. It has no special signifi-
cance.
(d) Auscultation. — Feeble breath-sounds are among the most character-
istic early signs, since not as much air enters the tubes and vesicles of the
affected area. It is well at first always to compare carefully the correspond-
ing points on the two sides of the chest without asking the patient either to
draw a deep breath or to cough. With early apical disease the inspiration
on quiet breathing may be scarcely audible. Expiration is usually prolonged.
On the other hand, there are cases in which the earliest sign is a harsh, rude,
respiratory murmur. On deep breathing it is frequently to be noted that
inspiration is jerking or wavy, the so-called " cog-wheel " rhythm ; which,
however, is by no means confined to tuberculosis. With extension of the
disease the inspiratory murmur is harsh, and, when consolidation occurs,
whiffing and bronchial. With these changes in the character of the murmur
there are rales, due to the accompanying bronchitis. They may be heard only
on deep inspiration or on coughing, and early in the disease are often crack-
ling in character. When softening occurs they are louder and have a bub-
bling, sometimes a characteristic clicking quality. These " moist sounds," as
they are called, when associated with change in the percussion resonance are
extremely suggestive. When cavities form, the rales are louder, more gur-
gling, and resonant in quality. When there is consolidation of any extent
the breath-sounds are tubular, and in the large excavations loud and cavern-
ous, or have an amphoric quality. In the unaffected portions of the lobe
and in the opposite lung the breath-sounds may be harsh and even puerile.
The vocal resonance is usually increased in all stages of the process, and
bronchophony and pectoriloquy are met with in the regions of consolidation
and over cavities. Pleuritic friction may be present at any stage and, as men-
tioned before, occurs very early. There are cases in which it is a marked
feature throughout. When the lappet of lung over the heart is involved there
may be a pleuro-pericardial friction, and when this area is consolidated there
TUBERCULOSIS. 331
may be curious clicking rales synchronous with the heart-beat, due to the com-
pression by the heart of this portion with expulsion of air from it. An
interesting auscultatory sign, met most commonly in phthisis, is the so-called
cardio-respiratory murmur, a whiffing systolic bruit due to the propulsion of
air out of the tubes by the impulse of the heart. It is best heard during
inspiration and in the antero-lateral regions of the chest.
A systolic murmur is frequently heard in the subclavian artery on either
side, the pulsation of which may be very visible. The murmur is in all prob-
ability due to pressure on the vessels by the thickened pleura.
The signs of cavity may be here briefly enumerated.
(a) When there is not much thickening of the pleura or condensation
of the surrounding lung-tissue, the percussion sound may be full and clear,
resembling the normal note. More commonly there is defective resonance
or a tympanitic quality which may at times be purely amphoric. The pitch
of the percussion note changes over a cavity when the mouth is opened or
closed (Wintrich's sign), or it may be brought out more clearly on change
of position. The cracked-pot sound is obtainable only over tolerably large
cavities with thin walls. It is best elicited by a j&rm, quick stroke, the patient
at the time having the mouth open. In those rare instances of almost total
excavation of one lung the percussion note may be amphoric in quality, (h)
On auscultation the so-called cavernous sounds are heard : ( 1 ) Various grades
of modified breathing — blowing or tubular, cavernous or amphoric. There
may be a curiously sharp hissing sound, as if the air was passing from a
narrow opening into a wide space. In very large cavities both inspiration
and expiration may be typically amphoric. (2) There are coarse bubbling
rales which have a resonant quality, and on coughing may have a metallic
or ringing character. On coughing they are often loud and gurgling. In
very large thin-walled cavities, and more rarely in medium-sized cavities,
surrounded by recent consolidation, the rales may have a distinctly amphoric
echo, simulating those of pneumothorax. There are dry cavities in which no
rales are heard. (3) The vocal resonance is greatly intensified, and whispered
pectoriloquy is clearly heard. In large apical cavities the heart-sounds are
well heard, and occasionally there may be an intense systolic murmur, prob-
ably always transmitted to, and not produced, as has been supposed, in the
cavity itself. In large excavations of the left apex the heart impulse may
cause gurgling sounds or clicks synchronous with the systole. They may
even be loud enough to be heard at a little distance from the chest wall. A
large cavity with smooth walls and thin fluid contents may give the succus-
sion sound when the trunk is abruptly shaken (Walshe), and even the coin
sound may be obtained.
Pseudo-cavernous signs may be caused by an area of consolidation near a
large bronchus. The condition may be most deceptive — the high-pitched or
tympanitic percussion note, the tubular or cavernous breathing, and the reso-
nant rales, simulate closely those of cavity.
3. Complications of Pulmonary Tuberculosis.
(1) In the Respiratory System. — The larynx is rarely spared in chronic
pulmonary tuberculosis. The first symptom may be huskiness of the voice.
There are pain, particularly in swallowing, and a cough which is often wheez-
332 SPECIFIC INFECTIOUS DISEASES.
ing, and iu the later stages very ineffectual. Aphonia and dysphagia are the
two most distressing s}Tnptoms of the laryngeal involvement. When the epi-
glottis is seriously diseased and the ulceration extends to the lateral wall of
the pharynx, the pain in swallowing may be very intense, or, owing to the
imperfect closure of the glottis, there may be coughing spells and regurgita-
tion of food through the nostrils. Bronchitis and tracheitis are almost invari-
able accompaniments.
Pneumonia is a not infrequent terminal complication of chronic phthisis.
It may run a perfectly normal course, while in other instances resolution may
be delayed, and one is in doubt, in spite of the abruptness of the onset, as
to the presence of a simple or a tuberculous pneumonia.
Emphysema of the uninvolved portions of the lung is a common feature,
rare!}' producing any special s3Tiiptoms. There are, however, cases of chronic
tuberculosis in which emphysema dominates the picture, and in which the
condition comes on slowly during a period of many years. (General subcu-
taneous emphysema, which has been met with in a few rare cases, is due either
to perforation of the trachea or to the rupture of a cavity closely adherent to
the chest wall.)
Gangrene of the lung is an occasional event in chronic pulmonary tuber-
culosis, due in almost all instances to sphacelus in the walls of the cavity,
rarely in the lung-tissue itself.
Complications in the Pleura. — A dry pleurisy is a very common accom-
paniment of the early stages of tuberculosis. It is always a conservative, use-
ful process. In some cases it is very extensive, and friction murmurs may
be heard over the sides and back. The cases with dry pleurisy and adhesions
are of course much less liable to the dangers of pneumothorax. Pleurisy
with effusion more commonly precedes than occurs in the course of pulmonary
tuberculosis. Still, it is common enough to meet with cases in which a sero-
fibrinous effusion arises in the course of the chronic disease. There are cases
in which it is a special feature, and it often, I think, favors chronicity. A
patient may during a period of four or five years have signs of local disease
at one apex with recurring effusion in the same side. Owing to adhesions in
different parts of the pleura, the effusion may be encapsulated. H^emorrhagic
effusions, which are not uncommon in connection with tuberculous pleurisy,
are comparatively rare in chronic phthisis. Chyliform or milk}^ exudates are
sometimes found. Purulent effusions are not frequent apart from pneumo-
thorax. An empyema, however, may occur in the course of the disease or as
a sequence of a sero-fibrinous exudate. Pneumothorax is an extremely com-
mon complication. Of 49 eases at the Johns Hopkins Hospital, 23 were
tuberculous (Emerson). It may prove fatal in twenty-four hours. ' In other
mstances a pyo-pneumothorax follows and the patient lingers for weeks or
months. In a third group of cases it seems to have a beneficial effect on the
course of the disease.
(2) Symptoms referable to other Organs.— (a) Cardio-vascular.—
The retraction of the left upper lobe exposes a large area of the heart. In
thm-chested subjects there may be pulsation in the second, third, and fourth
interspaces close to the sternum. Sometimes with much retraction of the
left upper lobe the heart is drawn up. A systolic murmur over the pulmo-
nary area is common in aU stages of phthisis. Apical murmurs are also not
TUBERCULOSIS. 333
infrequent and may be extremely rough and harsh without necessarily indi-
cating that endocarditis is present. The association of heart-disease with
phthisis is not, however, very uncommon. As already mentioned, there were
13 instances of endocarditis in 216 autopsies. The arterial tension is usually
low in phthisis and the capillary resistance lessened so that the pulse is often
full and soft even in the later stages of the disease. The capillary pulse is
not infrequently met with, and pulsation of the veins in the back of the hand
is occasionally to be seen.
(h) Blood Glandular System. — The early anasmia has already been noted.
It is often more apparent than real, a chloro-ansemia, and the blood-count
rarely sinks below two millions per cubic millimetre.
The blood-plates are, as a rule, enormiously increased and are seen in the
withdrawn blood as the so-called Schultze's granule masses. Without any
significance, they are of interest chiefly from the fact that every few years
some tyro announces their discovery as a new diagnostic sign of phthisis.
The leucocytes are greatly increased, particularly in the later stages.
(c) Gastro-intestinal System. — The tongue is usually furred, but may
be clean and red. Small aphthous ulcers are sometimes distressing. A red
line on the gums, a symptom to which at one time much attention was paid
as a special feature of phthisis, occurs in other cachectic states. Extensive
tuberculous disease of the pharynx, associated with a similar affection of the
larynx, may interfere seriously with deglutition and prove a very distressing
^nd intractable symptom. H. M. Hayes has studied the saliva and finds a
marked impairment in its digestive powers.
Tuberculosis of the stomach is rare. Ulceration may occur as an acci-
dental complication and multiple catarrhal ulcers are not uncommon. Inter-
stitial and parenchymatous changes in the mucosa are common (possibly asso-
ciated with the venous stasis) and lead to atrophy, but these can not always
be connected, with the symptoms, and they may be found when not expected.
On the other hand, when the gastric symptoms have been most persistent the
mucosa may show very little change. It is impossible always to refer the
anorexia, nausea, and vomiting of consumption to local conditions. The
hectic fever and the neurotic influences, upon which Immermann lays much
stress, must be taken into account, as they play an important role. The organ
is often dilated, and to muscular insufficiency alone may be due some of the
cases of dyspepsia. The condition of the gastric secretion is not constant,
and the reports are discordant. In the early stages there may be superacidity ;
later, a deflciency of acid.
Anorexia is often a marked symptom at the. onset ; there may be positive
loathing of food, and even small quantities cause nausea. Sometimes, with-
out any nausea or distress after eating, the feeding of the patient is a daily
battle. When practicable, Debove's forced alimentation is of great benefit
in such cases. Nausea and vomiting, though occasionally troublesome at an
early period, are more marked in the later stages. The latter may be caused
by the severe attacks of coughing. S. H. Habershon refers to four different
causes the vomiting in phthisis: (1) central, as from tuberculous menin-
gitis; (3) pressure on the vagi by caseous glands; (3) stimulation from the
peripheral branches of the vagus, either pulmonary, pharyngeal, or gastric;
and (4) mechanical causes.
334 SPECIFIC INFECTIOUS DISEASES.
Of the intestinal symptoms diarrhoea is the most serious. It may come
on early, but is more usually a s^Tnptom of the later stages^ and is associ-
ated with ulceration, particularly of the large bowel. Extensive ulceration
of the ileum may exist without any diarrhoea. The associated catarrhal
condition may account in part for it, and in some instances the amyloid degen-
eration of the mucous membrane.
(d) Nervous System.-^{1) Focal lesions due to the development of coarse
tubercles and areas of tuberculous meningo-encephalitis. Aphasia, for in-
stance, may result from the growth of meningeal tubercles in the fissure of
Sylvius, or even hemiplegia may occur. The solitary tubercles are more com-
mon in the chronic phthisis of children. (2) Basilar meningitis is an occa-
sional complication. It may be confined to the brain, though more commonly
it is a (3) cerebro-spinal meningitis, which may come on in persons without
well-marked local signs in the chest. Twice have I known strong, robust
men brought into hospital with signs of cerebro-spinal meningitis, in whom
the existence of pulmonary disease was not discovered until the post mortem.
(4) Periplieral neuritis, which is not common, may cause an extensor paraly-
sis of the arm or leg, more commonly the latter, with foot-drop. It is usually
a late manifestation. (5) Mental sjnnptoms. It was noted, even by the
older writers, that consumptives had a peculiarly hopeful temperament, and
the spes pMliisica forms a curious characteristic of the disease. Patients
with extensive cavities, high fever, and too weak to move will often make
plans for the future and confidently expect to recover.
Apart from tuberculosis of the brain, there is sometimes in chronic phthi-
sis a form of insanity not unlike that which occurs in the convalescence from
acute affections.
(e) A remarkable hypertrophy of the mammary gland may occur in pul-
monary tuberculosis, most commonly in males. It may be only on the affected
side. It is a chronic interstitial, non-tuberculous mammitis (Allot). Mas-
titis adolescentium, not very uncommon, is not necessarily suggestive of pul-
monary tuberculosis.
(/) Genito-urinary System. — The urine presents no special peculiarities
in amount or constituents. Fever, however, has a marked influence upon it.
Albumin is met with frequently and may be associated with the fever, or is
the result of definite changes in the kidneys. In the latter case it is more
abundant and more curd-like. Amyloid disease of the kidneys is not uncom-
mon. Its presence is shown by albumin and tube-casts, and sometimes by a
great increase in the amount of urine. In other instances there is drops}^, and
the patients have aU the characteristic features of chronic Bright's disease.
Pus in the urine may be due to disease of the bladder or of the pelves
of the kidneys. In some instances the entire urinary tract is involved. In
pulmonary phthisis, however, extensive tuberculous disease is rarely found
in the urinary organs. Bacilli may occasionally be detected in the pus.
Haematuna is not a very common symptom. It may occur occasionally as a
result of congestion of the kidneys, and pass off leaving the urine albuminous.
In other instances it results from disease of the pelvis or of the bladder, and
is associated either with early tuberculosis of the mucous membranes or more
commonly with ulceration. In any medical clinic the routine inspection of
the testes for tubercle will save two or three mistakes a year.
TUBERCULOSIS. 335
{g) Cutaneous System. — The skin is often dry and harsh. Local tuber-
cles occasionally occur on the hands. There may be pigmentary staining,
the chloasma phthisicorum, which is more common when the peritonaeum is
involved. Upon the chest and back the brown stains of pityriasis versicolor
are very frequent. The hair of the head and beard may become dry and
lanky. The terminal phalanges, in chronic cases, become clubbed and the
nails incurvated — the Hippocratic fingers. A remarkable and unusual com-
plication is general emphysema, which may result from ulceration of an
adherent lung or perforation of the larynx.
Diagnosis. — The early diagnosis of pulmonary tuberculosis is of such vital
importance to the patient that every possible means should be taken to recog-
nize the disease before it has made much headway. The truth is, a majority
of the cases come before us when the lesion is already advanced, as indi-
cated by the physical signs. The following points should be specially
attended to :
1. General Features. — Failing health, loss in weight and anaemia, with
slight cough, particularly at night, are rarely absent. It is usually for these
symptoms that the patient or his friends seek relief. Or there has been a
slight haemoptysis.
2. The Local Examination. — In very many cases the physical signs are
quite well marked, deficient expansion, the prominence of one clavicle, the
changes in the percussion note, the changes in the respiratory murmur, and
the clicking rales. In other instances the physical signs are indefinite, and
it is not possible to say after the most careful examination that there is a
suspicious focus in either lung.
3. Examination of the Sputum. — Bacilli and elastic tissue may be pres-
ent without definite physical signs. They may come from a very small focus
not discoverable on examination. In a great majority of early cases repeated
inspection of the sputum is the most important diagnostic measure. It is
very often difficult to get the sputum in incipient cases.
4. Tuberculin may be given or the ophthalmic reaction tested.
5. The agglutination and serum diagnosis, as practised by Arloing and
Courmont, may turn out to be of great service in doubtful cases.
4. Fibroid Phthisis.
In their monograph on Fibroid Diseases of the Lung (1894) Clark, Had-
ley and Chaplin make the following classification: 1. Pure fibroid; fibroid
phthisis — a condition in which there is no tubercle. 2. Tuberculo-fibroid dis-
ease— a condition primarily tuberculous, but which has run a fibroid course.
3. Fibro-tuberculous disease — a condition primarily fibroid, but which has
become tuberculous. The tuberculo-fibroid form may come on gradually as a
sequence of a chronic tuberculous broncho-pneumonia, or follow a chronic
tuberculous pleurisy. In other instances the process supervenes upon an ordi-
nary ulcerative phthisis. The disease becomes limited to one apex, the cavity
is surrounded by layers of dense fibrous tissue, the pleura is thickened, and
the lower lobe is gradually invaded by the sclerotic change. Ultimately a
picture is produced little if at all different from the condition known as
cirrhosis of the lungs. It may even be difficult to say that the process is
tuberculouSj but in advanced cases the bacilli are usually present in the walls
336 SPECIFIC INFECTIOUS DISEASES.
of the cavity at the apex, or old, encapsulated caseous areas are present, or
there may be tubercles at the apex of the other lung and in the bronchial
glands. Dilatation of the bronchi is present; the right ventricle, sometimes
the entire heart, is hypertropliied.
The disease is chronic, lasting from ten to twenty or more years, during
which time the patient may have fair health.
The chief symptoms are cough, often paroxysmal in character and most
marked in the morning, and dyspnoea on exertion. The expectoration is puru-
lent, and in some instances, when the bronchiectasis is extensive, fetid. There
is rarely any fever.
The physical signs are very characteristic. The chest is sunken and the
shoulder lower on the affected side; the heart is often drawn over and dis-
placed. If the left lung is involved there may be an unusually large area of
cardiac pulsation in the third, fourth, and fifth interspaces. Heart-murmurs
are common. There are dulness over the affected side and deficient tactile
fremitus. At the apex there may be well-marked cavernous sounds; at the
base, distant bronchial breathing. The condition may persist for years. In
some cases the other lung becomes involved, or the patient has repeated attacks
of hffimopt3^sis, in one of which he dies. As a result of the chronic suppura-
tion, amj'loid degeneration of the liver, spleen, and intestines may take place ;
dropsy frequently supervenes from failure of the right heart.
A more detailed account is found under Cirrhosis of the Lung, with which
this form is clinically identical.
Concurrent Infections in Pulmonary Tuberculosis. — It has long been
known that in pulmonary tuberculosis organisms other than the specific bacilli
are present, particularly Micrococcus lanceolatus, Streptococcus pyogenes, and
Staphylococcus aureus; less frequently Bacillus pyocyaneus.
A majority of all cases of pulmonary tuberculosis are combined infec-
tions; streptococci and pneumococci may be found in the sputa, and the
former have been isolated from the blood. Prudden, who has very carefully
studied this question, arrives at the following conclusions: The pulmonary
lesions of tuberculosis are subject to variations depending largely on the dif-
ferent modes of distribution of the bacilli, whether by the blood-vessels or
through the bronchi, and also whether a concurrent infection with other
organisms has taken place. The pneumonia complicating tuberculosis may
be the direct result of the tubercle bacillus or its toxins, or it may follow
secondary infection with other germs, particularly the Streptococcus pyogenes,
the Micrococcus lanceolatus, and the Staphylococcus pyogenes. The frequency
of this secondary infection and the relative significance of these germs are
not yet fully decided. The introduction of the tubercle bacilli into the lungs
of a rabbit through the trachea induces the various phases of pulmonary tuber-
culosis, but cavity formation is rare. If, on the other hand, into the lungs
of a rabbit which are the seat of extensive consolidation the Streptococcus
pyogenes h mtroduced, then cavities form rapidly, and the anatomical picture
IS very simHar to that of chronic ulcerative tuberculosis in man. It is very
probable that in man, too, the effect of contamination with these pus organ-
isms is a very important one in hastening necrosis and softening, and also
m the chronic cases they doubtless produce in large amounts the toxins which
are responsible for many of the symptoms of the disease.
TUBERCULOSIS. 337
Diseases associated with Pulmonary Tuberculosis. — Lobar pneumonia is
a not uncommon cause of death. It is met with, most frequently indeed, as
a terminal event in the chronic cases. It may, however, occur early, and be
difficult to distinguish from an acute caseous pneumonia. The sputa in the
latter are rarely rusty, while the fever in the former is more continuous and
higher, but in many cases it is impossible to differentiate between the two
conditions.
The association of tuberculosis and typhoid fever has already been dis-
cussed (page 90).
Erysipelas not infrequently attacks old poitrinaires in hospital wards and
almshouses. There are instances in which the attack seems to be beneficial,
as the cough lessens and the symptoms ameliorate. It may, however, prove
fatal.
The eruptive fevers, particularly measles, frequently precede, but rarely
occur in the course of pulmonary tuberculosis. In the revaccination of a
tuberculous subject the vesicles run a normal course.
Fistula in ano is associated with phthisis in an interesting manner. In
a majority of such cases it is a tuberculous process. The general affection may
progress rapidly after an operation. The question is considered in tubercu-
losis of the alimentary canal.
Heart-disease. — Cardiac hypoplasia seems uncommon in tuberculosis,
though it was much referred to by the older writers. It was present in only
3 cases in 1,764 autopsies on tuberculous patients (JSTorris). Rokitansky
taught that there was an antagonism between valvular lesions and aneurisms
and tuberculosis. All forms of congenital heart-disease predispose to it, par-
ticularly stenosis of the pulmonary artery. Mitral stenosis, on the other hand,
has a distinctly inhibitory influence. The two conditions are rarely found
associated. Endocarditis has already been referred to. A terminal acute
tuberculosis, particularly of the serous membranes, is not at all uncommon
in cardio-vascular diseases.
In chronic and arrested phthisis arteriosclerosis and phleho-sclerosis are
not uncommon. Ormerod noted 30 cases of chronic renal disease in 100
post mortems.
The .association of tuberculosis with chronic arthritis, upon which cer-
tain writers lay stress, finds its explanation in the lowered resistance of these
patients, and the greater liability to infection in the institutions in which so
many of them live.
Peculiarities of Pulmonary Tuberculosis at the Extremes of Life. — (a)
Old Age. — It is remarkable how common tuberculosis is in the aged, partic-
ularly in institutions. McLachlan noted 145 cases in which tuberculosis was
the cause of death in old persons in Chelsea Hospital. All were over sixty
years of age. The experience at the Salpetriere is the same. Laennec met
with a case in a person over ninety-nine years of age.
At the Philadelphia Hospital, in the bodies of aged persons sent over
from the almshouse it was extremely common to find either old or recent
tuberculosis. A patient died under my care at the age of eighty-two with
extensive peritoneal tuberculosis. Pulmonary tuberculosis in the aged is
usually latent and runs a slow course. The physical signs are often masked
by emphysema and by the coexisting chronic bronchitis. The diagnosis may
338 SPECIFIC INFECTIOUS DISEASES.
depend entirely upon the discovery of the bacilli and elastic tissue. Contrary
to the opinion which was held some years ago, tuberculosis is by no means
uncommon with senile emphysema. Some of the cases of tuberculosis in
the aged are instances of quiescent disease which may have dated from an
early period.
(h) Infants. — The occurrence of acute tuberculosis in children has
already been mentioned, and also the fact that the disease is occasionally con-
genital. Leroux has. analyzed the statistics of the late Prof. Parrot, em-
bracing 219 cases in children under three years. Of these there were from
one day to three months, 23 ; from three to six months, 46 ; from six to twelve
months, 53 (a total of 111 under one year) ; and from one to three years, 108.
Pulmonary cavities were present in 57 of the cases, and in only 50 was the
pulmonary lesion the sole manifestation. At the St. Petersburg Foundling
Asylum, in the ten years ending 1884, there were 416 cases of tuberculosis
in 16,581 autopsies. The observations of jSTorthrup, at the New York
Foundling Hospital, are of special interest in connection with the mode of
infection. Of 125 cases of tuberculosis on the records of this institution,
in 34 the ravages were extensive, the seat of the primary affection was not
clear, and the bronchial glands were large and cheesy. In 20 cases of general
tuberculosis there were cheesy masses in the bronchial glands and in the lungs.
In 42 cases of general tuberculosis the only cheesy masses were in the bronchial
hmph-glands. In 9 cases the tubercles were limited to the bronchial nodes
and the lungs; the latter containing only discrete miliary bodies, while the
bronchial glands showed advanced caseation. In 13 cases there was tuber-
culosis of the bronchial nodes only. In most of these cases the patients died
of infectious diseases. These figures are very suggestive, and point, as already
noted, to infection through the bronchial passages as the most common method,
even in children. Of 500 autopsies in children at the Munich Pathological
Institute, in 150 (30 per cent) tuberculosis was present and in over 92 per
cent the lungs were involved (Miiller).
Modes of Death in Pulmonary Tuberculosis. — (a) Bij asthenia, a gradual
failure of the strength. The end is usually peaceable and quiet, occasion-
ally disturbed by paroxysms of cough. Consciousness is often retained until
near the close.
(6) By asphyxia, as ia some cases of acute miliary tuberculosis and in
acute pneumonic phthisis. In chronic phthisis it is rarely seen, even when
pneumothorax develops.
(c) By syncope. This is not common. I have known it to happen once
or twice ia patients who insisted upon going about when in the advanced
stages of the disease. There may be, but not necessarily, fatty degeneration
of the heart. Eapid s}Ticope may follow hasmorrhage or may be due to throm-
bosis or emboHsm of the pulmonary artery, or to pneumothorax.
(d) From hcemorrhage. The fatal bleeding in chronic phthisis is due
to erosion of a large vessel or rupture of an aneurism in a pulmonary cavity,
most commonly the latter. Of 26 cases analyzed by S. West, in 11 the fatal
haemoptysis was due to aneurism, and of 35 cases collected by Percy Kidd,
aneurism was present in 30. In a case of Curtin's, at the Philadelphia Hos-
pital, the bleeding proved fatal before hemoptysis occurred, as the eroded
vessel opened into a capacious cavity.
TUBERCULOSIS. 339
(e) With cerebral symptoms. Coma may be due to meningitis, less often
to urgemia. Death in convulsions is rare. The hsemorrhagic pachy-menin-
gitis which occurs in some cases of phthisis occasionally causes loss of con-
sciousness, but is rarely a direct cause of death. In one of my cases, death
resulted from thrombosis of the cerebral sinuses with symptoms of meningitis.
Y. Tuberculosis of the Alimentary Caxal.
(a) Lips. — Tuberculosis of the lip is very rare. It occurs occasionally in
the form of an- ulcer, either alone or more commonly in association with laryn-
geal or pulmonary disease. Two cases are reported and the literature is
analyzed in Verneuil's Etudes.* The ulcer is usually very sensitive and may
be mistaken for a chancre or an epithelioma. The diagnosis may be made in
cases of doubt by inoculation or the examination of a portion for tubercle
bacilli.
(&) Tongue. — The disease begins by an aggregation of small granular
bodies on the edge or dorsum. Ulceration proceeds, leaving an irregular sore
with a distinct but uneven margin, and a rough, often caseous base. The
disease extends slowly and may form an ulcer of considerable size. I have
known it to be mistaken for epithelioma and the tongue to be excised. It is
rarely met with except when other organs are involved. The glands of the
angle of the jaw are not enlarged and the sore does not yield to iodide of
potassium, which are points of distinction between the tuberculous and the
syphilitic ulcer. In doubtful cases the inoculation test should be made, or a
portion excised for microscopical examination.
(c) The salivary glands belong to that small group of organs of the body
which seem to possess an immunity; a very few cases have been reported.
(d) Tubercles of the hard or soft palate nearly always follow extension of
the disease from neighboring parts.
(e) Tuberculosis of the Tonsils. — In 7 of 45 consecutive cases in children
from three months to fifteen years A. Latham demonstrated, by inoculation,
the presence of tuberculosis of the tonsils either in organs removed by oper-
ation or post mortem. The observation is of interest in connection with the
views of Schlenker, who claims that the majority of the cases of tuberculous
cervical glands result from infection with tubercle bacilli which gain admis-
sion by way of the tonsil. A large number of his cases of tuberculous cervical
adenitis were definitely of a descending variety and associated with tubercu-
losis of these glands. The majority also had pulmonary tuberculosis, and he
regards surface infection of the tonsil by tuberculous food and sputum far
more common than infection by way of the circulation. The disease may
occur as a superficial ulceration. More commonly there is an infiltration of
the tonsil with miliary tubercles, which produces a greater or less hypertrophy
which it is practically impossible to distinguish from an ordinary enlargement
of the tonsil without a microscopical examination. Hugh Walsham's observa-
tions on the frequency of infection of the tonsils in pulmonary tuberculosis
have been referred to.
(/) Pharynx. — In extensive laryngeal tuberculosis an eruption of miliary
granules on the posterior wall of the pharjmx is not very uncommon. In
* Tome iii, Fasc. I.
340 SPECIFIC INFECTIOUS DISEASES.
chronic phthisis an ulcerative pharjTigitis, due to extension of the disease
from the epiglottis and lar}Tix, is one of the most distressing of complica-
tions, rendering deglutition acutely painful. Adenoids of the naso-pharjTix
may be tuberculous, as shown by Lermo3'ez. Macroscopically, they do not
differ from the ordinary vegetations found in this situation.
(g) A few instances occur in the literature of tuberculosis of the (esoph-
agus. The condition is a pathological curiosity, except in the slight exten-
sion from the lar}Tix, which is not infrequent ; but in a case in my wards de-
scribed by Flexner the ulcer perforated and caused purulent pleurisy. The
condition has been fully considered by Claribel Cone, who has described a
second case from the Jolins Hopkins Hospital (Bulletin, Xovember, 1897).
{li) Stomach. — Many cases are reported which are doubtful. Primary
disease is unknown. Marfan was able to collect only about a dozen authentic
cases. Perforation of the stomach occurred six times, thrice by a tuberculous
gland. In Oppolzer's case an rdcer of the colon perforated the organ. In
Musser's case there was a large tuberculous ulcer 3 X 14 inches in extent.
Three cases have been described from my wards by Alice Hamilton (J. H. H.
Bulletin, April, 1897).
{i) Intestines. — The tubercles may be (1) primary in the mucous mem-
brane, or more commonly (2) secondary to disease of the lungs, or in rare
cases the affection may (3) pass from the peritongeuni.
(1) Primary intestinal tuberculosis occurs most frequently in children,
in whom it may be associated with enlargement and caseation of the mesen-
teric glands, or with peritonitis. As stated on page 292, there is great dis-
crepancy in the statistics on this point — German 4 per cent, American 1 per
cent, English 18 per cent — and the question needs careful study. Biedert
gives 16 cases in 3,104 instances of tuberculosis in children. In adults pri-
mary intestinal tuberculosis is rare, occurring in but 1 instance in 1,000
autopsies upon tuberculous adults at the Munich Pathological Institute; but
now and then cases occur in which the disease sets in with irregular diar-
rhoea, moderate fever, and colick\' pains. In a few cases hsemorrhage has
been the initial symptom. Eegarded at first as a chronic catarrh, it is not
until the emaciation becomes marked or the signs of disease appear in the
lungs that the true nature is apparent. Still more deceptive are the cases in
which the tuberculosis begins in the cfficum and there are symptoms of appen-
dicitis— tenderness in the right iliac fossa, constipation, or an irregular diar-
rhoea and fever. These signs may gradually disappear, to recur again in a
few weeks and still further complicate the diagnosis. Fatal hsemorrhage has
occurred in several of my cases. Perforation may occur with the formation
of a pericsecal abscess, or perforation into the peritoneum may take place, or
in very rare instances there is partial healing with great thickening of the
walls and narrowing of the lumen.
(2) Secondary involvement of the bowels is very common in chronic pul-
monary tuberculosis, e.g., in 566 of the 1,000 Municli autopsies in tuber-
culosis .just referred to. In only three of these cases were the lungs not
involved. The lesions are chiefly in the ileum, cascum, and colon. The affec-
tion begins in the solitary and agminated glands or on the surface of or
within the mucosa. The caseation and necrosis lead to ulceration, which
may be very extensive and involve the greater portion of the mucosa of the
TUBERCULOSIS. 341
large and small bowels. In the ileum the Peyer's patches are chiefly involved
and the ulcers may be ovoid, but in the jejunum and colon they are usually
round or transverse to the long axis. The tuberculous ulcer has the follow-
ing characters: (a) It is irregular, rarely ovoid or in the long axis, more
frequently girdling the bowel; (&) the edges and base are infiltrated, often
caseous; (c) the submucosa and muscularis are usually involved; and {d)
on the serosa may be seen colonies of young tubercles or a well-marked tuber-
culous Ijrmphangitis. Perforation and peritonitis are not uncommon events
in the secondary ulceration. Stenosis of the bowel from cicatrization may
occur ; the strictures may be multiple.
Localized chronic tuberculosis of the iho-coBcal region is of great impor-
tance. The caecum may present a chronic hyperplastic tuberculosis, which not
uncommonly extends into the appendix. As a consequence of the changes
produced a definite tumor-like mass is formed in the right iliac fossa. This
varies in size, is usually elongated in a vertical direction, hard, slightly mov-
able, or bound down by adhesions and very sensitive to pressure. The tumor
simulates more or less closely a true neoplasm of this region, particularly car-
cinoma. The condition is characterized by gradual constriction of the lumen
of the bowel, periodic attacks of severe pain, and alternating diarrhoea and
constipation. The extremely localized character of the disease warrants an ex-
ploratory operation, as the results of enterectomy are remarkably favorable.
Of 11 cases reported by P. M. Caird 7 recovered. In a second form of this
disease, occurring less frequently than the former, there is no definite tumor-
mass to be felt, but a general induration and thickening in the right iliac
fossa similar to the local changes produced by a recurring appendicitis. In
this variety a fistula discharging fecal matter occasionally results. Both forms
may be distinguished from the diseases they simulate by the finding of tubercle
bacilli in the stools or in the discharge from the fistula when such exists.
Tuberculosis of the rectum has a special interest in connection with fistula
in ano, which, according to Spillman's statistics, occurs in about 3.5 per cent
of cases of pulmonary disease. In many instances the lesion has been shown
to be tuberculous. It is very rarely primary, but if the tissue on removal
contains bacilli and is infective the lungs are almost invariably found to be
involved. It is a common opinion that the pulmonary symptoms progress rap-
idly after the fistula is cut. This may have some basis if the operation con-
sists in laying the tract open, and not in a free excision.
(3) Extension from the peritonaeum may excite tuberculous disease in the
bowels. The affection may be primary in the peritongeum or extend from the
tubes in women or the mesenteric glands in children. The coils of intestines
become matted together, caseous and suppurating foci develop between the
folds, and perforation may take place between the coils.
VI. Tuberculosis of the Liver.
This organ is very constantly involved in (1) Miliary tuberculosis. This
is seen in acute generalized tuberculosis, though the granules may be small
and have to be looked for very carefully. In chronic tuberculosis miliary
tubercles are not at all uncommon in the liver. (2) Solitary tubercle. Occa-
sionally large tuberculous masses are found in the organ, sometimes associated
342 SPECIFIC INFECTIOUS DISEASES.
with perihepatitis, sometimes with tuberculous peritonitis, and in children
with tuberculous adenitis. In a few cases the masses are very large, though it
is only in exceptional cases that the tumor can be felt through the abdominal
wall. Occasionally the solitary tubercle becomes infected with pus organisms,
softens and forms an abscess. (3) Tuberculosis of the hile ducts; tuber-
culous cavities in the liver. This is by far the most characteristic tubercu-
lous change in the organ, and is not uncommon. It was well described by
Bristowe in 1858. The liver is enlarged, and section shows numerous small
cavities, which look at first like multiple abscesses in suppurative pylephlebitis,
but the pus is bile-stained and the whole process is a local tuberculous cholan-
gitis. (4) Tuberculous cirrhosis. With the eruption of miliary tubercles
there may be slight increase in the connective tissue, which is overshadowed
by the fatty change. In all the chronic forms of tubercle in this organ there
may be fibrous overgrowth. Hanot, who has described several varieties, states
that the condition may be primary. Practically it is very rare, except in
connection with chronic tuberculous peritonitis and perihepatitis, when the
organ may be much deformed by a sclerosis involving the portal canals and
the capsule, which may be greatly involved in a polyserositis.
VII. Tuberculosis op the Brain axd Cord.
Tuberculosis of the brain occurs as (a) an acute miliary infection caus-
ing meningitis and acute hydrocephalus; (b) as a chronic meningo-encepha-
litis, usually localized, and containing small nodular tubercles; and (c) as
the so-called solitary tubercle. Between the last two forms there are all
gradations, and it is rare to see the meninges uninvolved. The acute variety
has already been considered. I shall here consider the chronic form, which
comes on slowly and has the clinical characters of a tumor.
It is most common in the young. Of 148 cases collected by Pribram 118
were under fifteen years of age. Other organs are usually involved, partic-
ularly the lungs, the bronchial glands, or the bones. In rare instances no
tubercles are found elsewhere. They occur most frequently in the cerebellum ;
next in the cerebrum and then in the pons. The growths are often multiple'
in 100 out of 183 cases (Gowers). They range in size from a pea to a wal-
nut; large tumors occasionally occur, and sometimes an entire lobe of the
cerebellum is affected. On section the tubercle presents a grayish-yellow,
caseous appearance, usually firm and hard, and encircled by a translucent'
softer tissue. The centre of the growth may be semi-difQuent. . As in other
localities the tubercle may calcify. The tumors are as a rule attached to the
menmges, often to the pia at the bottom of a sulcus so that they look im-
bedded m the brain-substance. About the longitudinal fissure there may be
an aggregation of the growths, with compression of the sinus, and the forma-
tion of a thrombus. The tuberculous tumor not infrequently excites acute
menmgitis. In localized meningo-encephalitis the pia is thickened, tuber-
cles are adherent to the under surface and grow about the arteries. It 'is often
combined with cerebral softening from interference with the circulation. Sev-
eral of the most characteristic instances which I have seen were on the
meninges covering the insula. This form may occur in pulmonary tubercu-
losis, causing hemiplegia or aphasia which may persist for months.
TUBERCULOSIS. 343
The symptoms of tuberculous growths in the brain are those of tumor,
and will be considered in the section on the brain.
In the spinal cord the same forms are found. The acute tuberculous men-
ingitis has been considered and is almost always cerebro-spinal. The solitary
tubercle of the cord is rare. Herter has reported 3 cases and collected 24
from the literature. It was secondary in all save one case. The symptoms
are those of spinal tumor or meningitis.
VIII. Tuberculosis op the Genito-urtnart System.
The studies of the past few years, and particularly the work of surgeons
and gynaecologists, have taught us the great importance of tuberculosis of this
tract. Any part of the genito-urinary system may be invaded. The suc-
cessive involvement of the organs may be so rapid that unless the case has
been seen early it may be impossible to state with any degree of certainty
which has been the primary seat of infection. There may be simultaneous
involvement of various portions of the tract. In tuberculosis of the genito-
urinary system one always has to bear in mind the possibility of latent dis-
ease elsewhere in the body. As Bollinger says, tubercle bacilli may gain
admission at some part of the respiratory tract without producing any lesion
at the point of entrance, and finally reach a bronchial gland, where they
set up a tuberculous process of extremely slow development without producing
any symptoms. From this point bacilli may enter the blood stream and lodge
in the epididymis or testicle proper, and produce nodules which are readily
discovered, owing to the ease with which these parts are examined. Such a
case might be quite easily mistaken for one of primary genital tuberculosis,
whereas the true primary tuberculous focus is far distant.
Infection" of the genito-urinary tract occurs in various ways :
1. By Hereditary Transmission. — It has been met with in the foetus. The
comparative frequency of tuberculosis of the testicle in very young children
suggests very strongly that the uro-genital organs may be involved as a result
of direct transmission of the disease from the parents.
2. By infection from areas of tuberculosis already existing in the patient.
(a) Infection tJirougli the Blood. — In many cases uro-genital tuberculosis
is found at autopsy associated with disease of some distant organ, particu-
larly the lungs, and it would appear most probable that in them infection has
been through the blood-vessels. Jani's observations, which were published by
Weigert after the author's death, strongly support this theory. In studying
sections of the genital organs of patients who died of pulmonary tuberculosis,
he found tubercle bacilli in 5 out of 8 cases in the testicle, and in 4 out of 6
cases in the prostate, without in any instance finding microscopical evidences
of tubercles in these organs. The bacilli lay, in the testis, partly within and
partly close beside the cellular and granular contents of the seminal tubules,
while in the prostate they were always situated in the neighborhood of the
glandular epithelium.
(&) Infection from the Peritonceum. — This source of infection, in both
men and women, is much more frequent than is commonly supposed. The
intimale relationship between the peritonaeum and bladder in both subjects,
and with the vesiculae seminales and vasa deferentia in the male, allows of
344 SPECIFIC INFECTIOUS DISEASES.
a ready way of invasion of these organs by direct extension of the disease.
The peritona?iim is a frequent source of genital tuberculosis in the female.
No doubt many cases of tuberculosis of the Fallopian tubes originate from
this source. The fact that the fimbriated extremity of the tube is often most
seriously involved points rather strongly in this direction, although the fact
might be taken as a point in favor of blood infection, favored by its greater,
vascularity. Various observations go to show that the action of the cilia
lining the lumina of the Fallopian tubes tends to attract particles introduced
into the peritoneal cavity. Jani's observation is very interesting in this con-
nection, as showing the possibility of tubercle bacilli entering the tubes from
the peritoneal cavity without there being any tuberculous peritonitis. He
found typical tubercle bacilli in the lumen, in sections of a normal Fallopian
tube, in a woman who died of pulmonary and intestinal tuberculosis. The
explanation advanced was that the bacilli made their way through the thin
peritoneal coat from one of the intestinal ulcers, thus reaching the peritoneal
cavity, and thence were attracted into the Fallopian tube by the current pro-
duced by the action of the cilia lining the lumen. The intimate relationship
between tuberculous peritonitis and tuberculosis of the Fallopian tubes is
shown in the fact that the latter are affected in from 30 to 40 per cent of
the cases.
(c) Infection from otlier Organs liy Direct Extension. — The occurrence
of direct extension from the peritonaeum has already been mentioned. In
tuberculous ulceration of the intestine or rectum adhesions to the bladder
in the male or to the uterus and vagina in the female may occur, with result-
ing fistulae and a direct extension of the disease. Perirectal tuberculous
abscesses may lead to secondary involvement of some portion of the genito-
urinary tract. It must not be forgotten that tuberculosis of the vertebrae
may be followed by tuberculosis of the kidney as a result of direct extension
of the disease.
3. By Infection from Without. — Whether uro-genital tuberculosis may
occur as a result of the entrance of tubercle bacilli into the urethra or vagina
is still a disputed question. That bacilli gain admission to these passages dur-
ing coitus with a person the subject of uro-genital tuberculosis, or by the use
of foul instruments or syringes, seems quite probable. The possibility of
genital tuberculosis occurring in the female as a result of coitus with a male
the subject of tuberculosis in some portion of the genito-urinary system was
first suggested by Cohnheim, who stated, however, that it rarely, if ever,
occurred. Gartner's experiments have been referred to.
In a patient with intestinal tuberculosis the tubercle bacilli might acci-
dentally reach the urethra or vagina from the rectum.
Uro-genital tuberculosis is commonest between the ages of twenty and
forty years — that is, during the period of greatest sexual acti^dty. Males are
affected much more frequently than females, the proportion being 3 to 1.
This great difference is no doubt partly due to the more intimate relationship
between the urinary and genital systems in the former than in the latter. In
the male the urethra forms the common outlet for the two systems, while in
the female there is a separate outlet for each.
Once the uro-genital tract has been invaded, the disease is likely to spread
rapidly, and the method of extension is an important one. Quite frequently
TUBERCULOSIS. 345
there is direct extension, as when the bladder is involved secondarily to the
kidney by passage of the disease along the ureter, or where the tuberculous
process extends along the vas deferens to the vesiculse seminales. No doubt
surface inoculation occurs in some instances, and to this cause may be attrib-
uted a certain percentage of cases of vesical and prostatic disease following
tuberculosis of the kidney. Although this probability is acknowledged, there
is an element of doubt as to the possibility of the kidney becoming affected
secondarily to the bladder or prostate by the direct passage of the bacilli up
the lumen of one ureter; for in such a case we have to suppose that a non-
motile bacillus, contrary to the laws of gravity, ascends against an almost
constant current of urine flowing in the opposite direction. The lymphatics
may afford a means for the spreading of the disease, but in a greater number
of cases than is generally supposed it takes place by way of the blood-vessels.
Cystoscopic examinations of the bladder not infrequently show the presence
of tubercles beneath the mucous membrane before there is any evidence of
superficial ulceration — a fact suggesting strongly a blood infection.
The discovery of tubercle bacilli in the urine and the obtaining of tuber-
culous lesions in animals as a result of inoculation with the urinary sedi-
ment afford us the only positive evidence of genito-urinary tuberculosis. So
far there are no authentic accounts of tubercle bacilli having been found in the
semen of men with tuberculosis of the testicle or vesiculse seminales. Owing
to the fact that the smegma bacillus has the same staining reaction as the
tubercle bacillus, and, morphologically, is practically indistinguishable from
it, the greatest care must be used in obtaining the specimen of urine for
examination, to eliminate, if possible, all chances of contamination. Thus
the urine examined must be a catheterized specimen, and even then one runs
the risk of carrying back into the bladder on the end of the catheter a few
bacilli which may be washed out in the stream of urine and be mistaken for
tubercle bacilli in the sediment. By Bunge and Trautenroth's method of
staining the two organisms can probably be definitely differentiated, but the
safer plan is to immediately inoculate one or more guinea-pigs with some of the
suspected urine. If tubercle bacilli be present the animals will manifest
tuberculous lesions in from three to five weeks.
TuBEECULOSis OF THE KiDNEYS (PhtMsis renum) . — In general tuber-
culosis the kidneys frequently present scattered miliary tubercles. In pul-
monary tuberculosis it is common to find a few nodules in the substance of
the organ, or there may be pyelitis. In the first 17,000 admissions to the
medical wards of the Johns Hopkins Hospital there were 1,085 cases of tuber-
culous infection. In 17 of these a clinical diagnosis of renal tuberculosis
was made. Walker analyzed the first 1,369 autopsies in the same hospital
and found that 784 had tuberculosis in some part of the body. In all there
were 61 cases of renal tuberculosis. Of 482 cases of pulmonary tuberculosis
showing symptoms during life, one or both kidneys were involved in 23.
There were 36 cases of acute general miliary tuberculosis, and in every instance
the kidney was affected. The 2 other cases of renal tuberculosis occurred in
patients with latent disease. Primary tuberculosis of the kidneys is not very
rare, but in no instance in the above series did Walker demonstrate a primary
infection in the kidney. The tuberculous process was primary in some other
part of the genito-urinary tract in 6 cases. In a majority of the cases the
346 SPECIFIC INFECTIOUS DISEASES.
process involves the jDclvis and the ureter as well, sometimes the bladder and
prostate. It may be difficult to say in advanced cases whether the disease
has started in the bladder, prostate, or vesicles, and crept up the ureters,
or whether it started in the kidneys and proceeded downward. In a majority
of cases, I believe, the latter is true, and the infection is through the blood.
Walker thinks that a hematogenous infection takes place in 90 per cent of the
eases, and that this is the channel of infection in the majority of instances
where renal follows vesical tuberculosis rather than along the ureter. One
kidney alone may be involved, and the disease creeps down the ureter and
may only extend a few millimetres on the vesical mucosa. A man with aortic
insufficiency, who had no lesions in the lungs, presented a localized patch in
the pelvis of the kidney, involving a pyramid, while the ureter, 5 cm. from the
bladder and at its orifice, was thickened and tuberculous. The prostate
showed an area of caseation. The process is most common between twenty
and thirty years of age, but it may occur at the extremes of age. In a series
of 386 cases collected by Walker in which the sex was stated, 182 of the
patients were males and 204 females. The joint statistics of Guillard, Tuffier,
and Albarran include 246 cases of chronic tuberculosis, of which 117 were
females and 69 males. In the earliest stage, which may be met with acci-
dentally, the disease is seen to begin in the pyramids and calyces. Necrosis
and caseation proceed rapidly, and the colonies of tubercles start throughout
the pyramids and extend upon the mucous membrane of the pelvis. As a
rule, from the outset it is a tuberculous pyo-nephrosis. The renal infection
may result from direct extension of the disease from a tuberculous vertebra.
It may be confined to one kidney, or progress more extensively in one than in
the other. Of 216 cases in which the side affected was specified, the right
kidney was involved in 111, the left in 96, and both together in 9. At autopsy
both organs are usually found enlarged. In only 3 of the 61 autopsies pre-
viously referred to was the disease unilateral. One kidney may be completely
destroj^ed and converted into a series of cysts containing cheesy substance —
a form of kidney which the older writers called scrofulous. In the putty-
like contents of these cysts lime salts may be deposited. In other instances
the walls of the pelvis are thickened and cheesy, the pyramids eroded, and
caseous nodules are scattered through the organ, even to the capsule, which
may be thickened and adherent. The other organ is usually less affected,
and shows only pyelitis or a superficial necrosis of one or two pyramids.
The ureters are usually thickened and the mucous membrane ulcerated and
caseous. Involvement of the bladder, vesiculse seminales, and testes is not
uncommon in males.
The symptoms are those of pyelitis. The urine may be purulent for
years, and there may be little or no distress. Even before the bladder be-
comes involved micturition is frequent, and many instances are mistaken
for cystitis. The frequent micturition is in part due to an initial polyuria,
in part to reflex irritation, but chiefly to a non-tuberculous inflammation
over the trigone of the bladder. It is usually the earliest and most constant
symptom. Haematuria, of a mild grade, occurs at some time during the course
of the disease in the majority of the cases. Dull, aching pain in the lumbar
region on one side is frequently complained of and may be the first symptom.
The condition is for many years compatible with fair health. The curability
TUBERCULOSIS. 347
is shown by the accidental discovery of the so-called scrofulous kidney, con-
verted into cysts containing a putty-like substance. In cases in which the
disease becomes advanced and both organs are affected, constitutional symp-
toms are more marked. There is irregular fever, with chills and loss of
weight and strength. General tuberculosis is common. In only one of my
cases were the lungs uninvolved. In a case at the Montreal General Hos-
pital a cyst perforated and caused fatal peritonitis.
Physical examination may detect special tenderness on one side, or the
kidney may be palpable in front on deep pressure; but tuberculous pyelo-
nephritis seldom causes a large tumor. Occasionally the pelvis becomes
enormously distended; but this is rare in comparison with its frequency in
calculous pyelitis. The urine presents changes similar to those of ordinary
calculous pyelitis — pus-cells, epithelium, and occasionally definite caseous
masses. It is nearly always acid in reaction. Albumin is, of course, pres-
ent. Tubercle bacilli may be demonstrated by the ordinary methods. Tube-
casts are not often seen.
To distinguish the condition from calculous pyelitis is often difficult.
Haemorrhage may be present in both, though not nearly so frequently in the
tuberculous disease. Functional hsematuria, to which Senator has given the
name essential renal liwmaturia, and Klemperer that of angio-neurotic renal
Ticematuria has been a source of error in diagnosis and has led to surgical
interference. In this condition it is highly probable that bleeding from the
kidney can occur in the absence of any definite lesion of the organ, although
Israel denies the existence of such an anomaly. Methylene blue and phlorid-
zin, given subcutaneously, are held to be of value in determining the kidney
affected. The diagnosis rests on three points: (1) The detection of some
focus of tuberculosis, as in the testes; (2) the presence of tubercle bacilli in
the sediment; and (3) the use of tuberculin. In woman the kidney involved
is now easily determined by catheterizing the ureters after the plan of my
colleague Kelly.
The incidence of renal implication in uro-genital tuberculosis may be
gathered from Orth's Gottingen material, analyzed by Oppenheim. Of 60
cases there were 34 in which the kidneys were involved. Posner in 149 eases
found the bladder involved in 18, and the testes in 8.
Tuberculosis of the suprarenal capsules will be considered under Addison's
Disease.
Tuberculosis of the Ureter and Bladder. — This rarely occurs as
a primary affection, but is nearly always secondary to involvement of other
parts, particularly the pelvis of the kidney. In the case of uro-genital tuber-
culosis, above mentioned, in a patient who died of heart-disease, the ureter,
just where it enters the bladder, showed a fresh patch of tuberculosis.
Protracted cystitis, which has come on without apparent cause, is always
suggestive of tuberculosis. The renal regions, the testes, and the prostate
should be examined with care. It may follow a pyelo-nephritis, or be asso-
ciated with primary disease of the prostate or vesiculse seminales. Primary
tuberculosis of the posterior wall of the bladder may simulate stone.
Tuberculosis of the Prostate and Yesicul^ Seminales. — The
prostate is frequently involved in tuberculosis of the uro-genital tract. In
Krzyincki's cases, of 15 males the prostate was inyolved in 14 and the vesiculse
348 SPECIFIC INFECTIOUS DISEASES.
scmiiiales in 11. In Orth's cases the prostate was involved in 18 of the 37
cases in males. These parts are much more frequently involved than ordinary
post-mortem statistics indicate. Per rectum the prostatic lobes are felt to
he occupied by hard nodules varying in size from a pea to a bean. There is
great irritability of the bladder, and agonizing pain in catheterization. An
extremely rare lesion is primary urethral tuberculosis, which may simulate
stricture.
Tuberculosis op the Testes. — This somewhat common affection may
be primary, or, more frequently, is secondary to tuberculous disease else-
where. Many cases occur before the second year, and it is stated to have
been met with in the foetus. In infants it is serious and usually associated
with tuberculous disease in other parts. In 9 cases reported by Hutinel and
Deschamps, in every one there was a general affection. In 20 cases reported
by Jullien, 6 were under one year, and 6 between one and two years old. In
5 of the cases both testicles were affected. Koplik holds that most of the
instances of this 'kind are congenital, in Baumgarten's sense. In the adult
the tubercles begin within the substance of the gland, but in children the
tunica albuginea is first affected. The tubercle does not always undergo
caseation, but it may present a number of embryonic cells, not unlike a
sarcoma.
Tubercle of the testes is most likely to be confounded with syphilis. In
the latter the body of the organ is most often affected, there is less pain, and
the outlines of the growth are more nodular and irregular. In obscure peri-
toneal disease the detection of tubercle in a testis has not infrequently led
to a correct diagnosis. The association of the two conditions is not uncom-
mon. The lesion in the testis may heal completely, or the disease may become
generalized. General infection has followed operation. Too much stress can
not be laid on the importance of a routine examination of the testes in hos-
pital patients.
Tuberculosis of the Fallopian Tubes, Ovaries, and Uterus. — The
Fallopian iuhes are by far the most frequent seat of genital tuberculosis.
The disease may be primary and produce a most characteristic form of sal-
pingitis, in which the tubes are enlarged, the walls thickened and infiltrated,
and the contents cheesy. Adhesion takes place between the fimbrise and the
ovaries, or the uterus may be invaded. The condition is usually bilateral.
It may occur in young children. Although, as a rule, very evident to the
naked eye, there are specimens resembling ordinary salpingitis, which show
on microscopical examination numerous miliary tubercles (Welch and Wil-
liams). Tuberculous salpingitis may cause serious local disease with abscess
formation, and it may be the starting-point of peritonitis.
Tuberculosis of the ovary is always secondary. There may be an erup-
tion of tubercles over the surface in an extensive involvement of the stroma
with abscess formation.
Tuberculosis of the uterus is very rare. Only three examples have come
under my observation, all in connection with pulmonary phthisis. It may
be primary. The mucosa of the fundus is thickened and caseous, and tuber-
cles may be seen in the muscular tissue. Occasionally the process extends
to the vagina.
Tuberculosis of the placenta is more common than has been supposed.
TUBERCULOSIS. 349
Of 30 placentae from tuberculous women, 9 were affected; 5 of these were
from cases of advanced disease of the lung. The lesions are easily overlooked.
IX. Tuberculosis op the Mammary Gland.
Mandry (Bruns's Beitrage, viii) has collected 40 cases, 1 of which was
in a male. The disease is most common between the fortieth and sixtieth
years. The breast is frequently fistulous, unevenly indurated, and the nipple
is retracted. The fistulse and ulcers present a characteristic tuberculous
aspect. There is also a cold tuberculous abscess of the breast. The axillary
glands are affected in about two-thirds of the cases. The disease runs a
chronic course of months or years. The diagnosis can be made by the general
appearance of the fistulse and ulcers, and by the existence of tubercle bacilli.
The prognosis is not bad, if total eradication of the disease be possible.
In 1836 Bedor' described an hypertrophy of the breast in the subjects
of pulmonary tuberculosis. As a rule, if one gland is involved, usually on
the side of the affected lung, as already mentioned, the condition is one of
chronic interstitial mammitis, and is not tuberculous.
X. Tuberculosis op the Circulatory System.
(a) Myocardium. — -Scattered miliary tubercles are sometimes met with
in the acute disease. Larger caseous tubercles are excessively rare. A. Moser
states that there are only 46 cases on record. There is also a sclerotic tuber-
culous myocarditis. The infection often passes from a mediastinal gland.
(&) Endocardium. — In 216 autopsies in cases of chronic phthisis I found
endocarditis in 12. It was present in only 151 among more than 11,000
autopsies on tuberculous cases (G. W. ISTorris). As a rule, it is a secondary
form, the result of a mixed infection, so common in pulmonary tuberculosis.
A true tuberculous endocarditis does, hoAvever, occur, directly dependent upon
infection with the bacillus of Koch. As a rule, it is a vegetative endocardi-
tis, not to be distinguished from that caused by Streptococcus or Staphylo-
coccus. In rare cases, however, caseous tubercles develop.
(c) Arteries. — Primary tuberculosis of the larger blood-vessels is very
rare, and is usually the result of invasion from without. The disease may,
however, occur in a large artery and not result from external invasion. In
a case of chronic tuberculosis Plexner found a fresh tuberculous growth in
the aorta, which had no connection with cheesy masses outside the vessel.
Simmitsky has collected 18 cases of tuberculosis of the aorta.
In the lungs and other organs attacked by tuberculosis the arteries are
involved in an acute infiltration which usually leads to thrombosis, or tuber-
cles may develop in the walls and proceed to caseation and softening fre-
quently with a resulting haemorrhage. By extension into vessels, particu-
larly veins, the bacilli are widely distributed with the production of miliary
tuberculosis.
XL Diagnosis op Tuberculosis.
The recognition of the disease rests upon the macroscopical and micro-
scopical appearances of the lesions and the presence of the tubercle bacilli.
350 SPECIFIC INFECTIOUS DISEASES.
Tuberculin Beadion. — (a) Hypodermic. — In obscure internal lesions, in
joint eases, and in suspected tuberculosis of the kidneys this gives most valu-
able information. In adults a milligramme is injected subcutaneously, and
if this has no reaction a larger dose of two or three milligrammes is employed
in two or three days. There is often slight local irritation following injection,
and within ten to twelve hours the febrile reaction begins, the temperature
rising from 103° to 104°. (&) Conjunctival Reaction. — Calmette's test gives
very satisfactory results — of 2,894 clinically tuberculous patients, 92.05 per
cent reacted. A drop of ^-1 per cent solution of tuberculin is put into the
conjunctiva, which in infected individuals reacts with a hyperemia, (c) A
skin reaction also follows vaccination with tuberculin, but this is not so cer-
tain as the conjunctival reaction. Hamman's paper on tuberculin in pul-
monary tuberculosis (Arch, of Int. Med., 1908), gives the Johns Hopkins
Hospital experience. Influenced by Trudeau, it has been used there fifteen
or sixteen years in obscure medical and surgical cases with most satisfactory
results.
XII. The Peognosis in Tuberculosis,
The parable of the sower already referred to expresses better than in any
other way the question of individual predisposition. In a large propor-
tion of us the seed falls by the wayside. The bacilli are picked up by the
phagocytes in the air-passages, and never really enter the body. In others
the seed falling upon a rock or on stony ground withers away as soon
as it springs up; and such are the cases in which the bacilli gain entrance
to the bronchial glands and form small foci which rapidly heal. The seed
which falls among thorns represents the germs which gain entrance to the
lungs and which grow and cause the characteristic lesions, but the natural
protective processes limit and control it, and the patient is cured. In the
last group, in which the seed falls on good ground and springs up and bears
fruit a hundredfold, are the cases in which the disease progresses and the
unfortunate victim dies of tuberculosis. The late Austin Flint, facile princeps
among American students of the disease, called attention to its self-limitation
and intrinsic tendency to recovery in tuberculosis. Of his 670 cases, 44 recov-
ered, and in 31 the disease was arrested, spontaneously in 23 of the first
group and in 15 of the second. This natural tendency to cure is still more
strikingly shown in honphatic and bone tuberculosis.
The following may be considered favorable circumstances in the progno-
sis of pulmonary tuberculosis: An early diagnosis, a good family history,
previous good health, a strong digestion, a suitable environment, and an insidi-
ous onset, without high fever, and without extensive pneumonic consolidation.
Cases beginning with pleurisy seem to run a more protracted and more favor-
able course. Eepeated attacks of hemoptysis are unfavorable. When well
established the course of tuberculosis in any organ is marked by intervals of
weeks or months in which the fever lessens, the symptoms subside, and there
is improvement in the general health.
In pulmonary cases the duration is extremely variable. Laennec placed
the average duration at two years, and for the majority of cases this is perhaps
a correct estimate. Pollock's large statistics of over 3,500 cases show a mean
duration of the disease of over two years and a half. Williams's analysis of
TUBERCULOSIS. 351
1,000 cases in private practice shows a much more protracted course, as the
average duration was over seven years.
TuBEECULOSis AND Maeriage. — Under the subject of prognosis comes the
question of the marriage of persons who have had tuberculosis, or in whose
family the disease prevails. The following brief statements may be made
with reference to it :
(a) Subjects with healed lymphatic or bone tuberculosis marry with per-
sonal impunity and may beget healthy children. It is undeniable, however,
that in such families scrofula, caries of the bone, arthritis, cerebral and pul-
monary tuberculosis are more common. Which is it, " heredite de graine ou
heredite de terrain," as the French have it, the seed or the soil, or both ? We
can not yet say. The risks, however, are such as may properly be taken.
(&) The question of marriage of a person who has arrested or cured lung
tuberculosis is more difficult to decide. In a male, the personal risk is not
so great; and when the health and strength are good, the external environ-
ment favorable, and the family history not extremely bad the experiment —
for it is such — is often successful, and many healthy and happy families are
begotten under these circumstances. In women the question is complicated
with that of child-bearing, which increases the risks enormously. With a
localized lesion, absence of hereditary taint, good physique, and favorable
environment, marriage might be permitted. When tuberculosis has existed,
however, in a girl whose family history is bad, whose chest expansion is slight,
and whose physique is below the standard, the physician should, if possible,
place his veto upon marriage.
(c) With existing disease, fever, bacilli, etc., marriage should be prohib-
ited. Pregnancy usually hastens the process, though it may be held in abey-
ance. After parturition the disease advances rapidly. There is much truth,
indeed, in the remark of Dubois : "If a woman threatened with phthisis
marries, she may bear the first accouchement well; a second, with difficulty;
a third, never." Conception may occur in an advanced stage of the disease.
XIII. Prophylaxis in Tuberculosis.
(a) General. — Among the more important measures may be mentioned
the following: First, education of the public. Much has been done in this
direction by the antituberculosis crusade, which has resulted in the forma-
tion of many active societies, and has stimulated widespread interest in the
disease. Secondly, the placing of pulmonary tuberculosis on the list of re-
portable diseases. This gives the board of health control of the situation,
and, as the New York experience has demonstrated, is perhaps the most
helpful measure in the prophylaxis. Thirdly, the improved sanitary condition
of the poor, particularly with reference to the housing. Fourthly, direct pre-
ventive measures, such as the enactment of laws against spitting in public,
the proper disinfection and cleaning of the rooms and houses which have been
occupied by tuberculous patients, and the careful inspection of dairies and
abattoirs. Fifthly, in the large cities, organization of sanatoria and hospitals
for early curable and late incurable cases, and the establishment of separate
dispensaries with a system of visiting of the patients at their homes by specially
assigned nurses. Lastly, the care of the sputa of the consumptive. Thorough
352 SPECIFIC INFECTIOUS DISEASES.
boiling or putting it into the fire is sufficient. In hospitals it is well to have
printed directions as to the care of the sputa, and also printed cards for out-
patients, giving the most important rules. It should be explained to the
patient that the only risk, practically, is from this source.
(h) Individual. — Individual prophylaxis in the case of delicate children
is most important. An infant born of tuberculous parents, or of a family
in which consumption prevails, should be brought up with the greatest care
and guarded most particularly against catarrhal affections of all kinds.
Special attention should be given to the throat and nose, and on the first
indication of mouth-breathing, or any obstruction of the naso-pharynx, a
careful examination should be made for adenoid vegetations. The child
should be clad in flannel and live in the open air as much as possible, avoid-
ing close rooms. It is a good practice to sponge the throat and chest night
and morning with cold water. Special attention should be paid to diet and
to the mode of feeding. The meals should be at regular hours and the food
plain and substantial. From the outset the child should be encouraged to
drink freely of milk. Unfortunately, in these cases there seems to be an
uncontrollable aversion to fats of all kinds. As the child grows older, sys-
tematically regulated exercise or a course of pulmonary gymnastics may be
taken. In the choice of an occupation preference should be given to an out-of-
door life. Families with a marked predisposition to tuberculosis should, if
possible, reside in an equable climate.
The trifling ailments of children should be carefully watched. In the
convalescence from the fevers which so frequently prove dangerous, the great-
est caution should be exercised to prevent catching cold. Cod-liver oil, the
syrup of the iodide of iron, and arsenic may be given. As mentioned, care
of the throat in these children is very important. Enlarged tonsils should
be removed.
XIY. Treatment of Tubeeculosis.
I. The Natural or Spontaneous Cure. — The spontaneous healing of
local tuberculosis is an every-day affair. Many cases of adenitis and dis-
ease of the bone or of the joints terminate favorably. The healing of pul-
monary tuberculosis is shown clinically by the recovery of patients in whose
sputa elastic tissue and bacilli have been found; anatomically, by the pres-
ence of lesions in all stages of repair. In the granulation products and asso-
ciated pneumonia a scar-tissue is formed, while the smaller caseous areas
become impregnated with lime salts. To such conditions alone should the
term healing be applied. When the fibroid change encapsulates but does
not involve the entire tuberculous tissue, the tubercle may be termed involuted
or quiescent, but is not destroyed. When cavities of any size have formed,
healing, in the proper sense of the term, does not occur. I have yet to see
a specimen which would indicate that a vomica had cicatrized. Cavities may
be greatly reduced in size — indeed, an entire series of them may be so con-
tracted by sclerosis of the tissue about them that an upper lobe, in which this
process most frequently occurs, may be reduced to a third of its ordinary
dimensions. Laennec understood thoroughly this natural process of cure in
tuberculosis, and recognized the frequency with which old tuberculous lesions
occurred in the lungs. He described cicatrices completes and cicatrices
TUBERCULOSIS. 353
fistuleuses, the latter being the shrunken cavities communicating with the
bronchi; and remarked that, as tubercles growing in the glands, which are
called scrofula, often heal, why should not the same take place in the lungs ?
There is an old German axiom, " Jedermann hat am Ende ein hisclien
Tuherculose," a statement partly borne out by the statistics showing the pro-
portions of cases in persons dying of all disease in whom quiescent or tuber-
culous lesions are found in the lungs. We find at the apices the following
conditions, which have been held to signify healed tuberculous processes:
(1) Thickening of the pleura, usually at the posterior surface of the apex,
with subadjacent induration for a distance of a few millimetres. This has,
perhaps, no greater significance than the milky patch on the pericardium.
(3) Puckered cicatrices at the apex, depressing the pleura, and on section
showing a large pigmented, fibrous scar. The bronchioles in the neighborhood
may be dilated, but there are neither tubercles nor cheesy masses. This may
sometimes, but not always, indicate a healed tuberculous lesion. (3) Puck-
ered cicatrices with cheesy or cretaceous, nodules, and with scattered tubercles
in the vicinity. (4) The cicatrices fistuleuses of Laennec, in which the fibroid
puckering has reduced the size of one or more cavities which communicate
directly with the bronchi.
The investigations of Naegeli in Ribbert's laboratory show how frequent
tuberculous infection is, and how common recovery must be. A special exami-
nation was made of every organ of the body. In a series of cases tuberculous
lesions were found in 97 per cent in the bodies of adults. Up to the fifteenth
year they were present in only 50 per cent; then there was a sudden rise in
the eighteenth year to 96 per cent, and above the fortieth year a tuberculous
focus was found in every body. In a series of 500 post mortems studied with
reference to this point by Blumer and Lartigau, healed pulmonary lesions were
found in 30 per cent.
II. General Measures. — The cure of tuberculosis is a question of nutri-
tion; digestion and assimilation control the situation; make a patient grow
fat and the local disease may be left to take care of itself. There are three
indications: First, to place the patient in surroundings most favorable for
the maintenance of a maximum degree of nutrition; second, to take such
measures as, in a local or general way, influence the tuberculous processes;
third, to alleviate symptoms.
Open-air Treatment. — The value of fresh air and out-of-door life is well
illustrated by an experiment of Trudeau. Inoculated rabbits confined in a
dark, damp place rapidly succumbed, while others, allowed to run wild, either
recovered or show slight lesions. It is the same in human tuberculosis. A
patient confined to the house — particularly in the close, overheated, stuffy
dwellings of the poor, or treated in a hospital ward — is in a position analogous
to that of the rabbit confined to a hutch in the cellar ; whereas a patient living
in the fresh air and sunshine for the greater part of the day has chances
comparable to those of the rabbit running wild.
The open-air treatment of tuberculosis may be carried out at home, by
change of residence to a suitable climate, or in a sanatorium.
(a) At Home. — In a majority of all cases the patient has to be cared for
in his own home, and if in the city, under very disadvantageous circum-
stances. Much, however, mav be done even in cities to promote arrest by
24
354 SPECIFIC INFECTIOUS DISEASES.
insisting upon systematic treatment. How much may be done by care and
instruction is shown by the success of J. H. Pratt's tuherculosis classes. As
not five per cent of the patients can be dealt with in sanatoria^, it is surpris-
ing and gratifying to see how successful the home treatment may be. Even
in cities the patients may be trained to sleep out of doors, and the results
obtained by Pratt, Millett, and others are as good as any that have been pub-
lished. While there is fever the patient should he at rest in bed, and for the
greater part of each day, unless the weather is blustering and rainy, the
windows should be open, so that he may be exposed freely to the fresh air.
Low temperature is not a contraindication. If there is a balcony or a suit-
able yard, on the brighter days the patient may be wrapped up and put in a
reclining chair or on a sofa. The important thing is for the physician to
emphasize the fact that neither the cough, fever, night sweats, and not even
haemoptysis contraindicate a full exposure to the fresh air. In country places
this can be carried out much more effectively. In the summer the patient
should be out of doors for at least eleven or twelve hours, and in winter six or
eight hours. At night the room should be cool and thoroughly well ventilated.
It may require several months of this rest treatment in the open air before the
temperature falls to normal.
(6) Treatment in Sanatoria. — Perhaps the most important advance in
the treatment of tuberculosis has been in the establishment in favorable locali-
ties of institutions in which patients are made to live according to strict
rules. To Brehmer, of Gobersdorf, we owe the successful execution of' this
plan, which has been followed in Germany with most gratifying results. In
the United States the zeal, energy, and scientific devotion of Edward L.
Trudeau have demonstrated its feasibility, and the Saranac institution has
become a model of its kind. The results at Gobersdorf, Palkenstein, and
Saranac demonstrate the great importance of system and rigid discipline in
carrying out a successful treatment of tuberculosis. Much has been done
both in the United States and Great Britain to promote the sanatorium treat-
ment of tuberculosis. The past three years have been rich in experience. The
good results have quite justified the heavy expenditure of money. In many
places it has been demonstrated that with an inexpensive plant excellent
results may be obtained. A reaction has naturally followed the " stuffing "
plan of feeding, and more reasonable methods are now employed. The " abso-
lute rest " plan has been modified to meet individual cases. The system of
graduated work introduced by Patersin at Erimley has shown how beneficial
hard work is for the physical and moral condition of the consumptive. The
all-important matter is the establishment near to the large cities of public
sanatoria for the treatment of cases in the early stages. There should be
opened in the large general hospitals special out-patient departments for
tuberculous patients, from which suitable cases could be sent to the civic sana-
toria. They could be partly self-supporting, as many patients would pay a
reasonable sum per month. A useful Directory of Institutions for Tubercu-
losis in the United States and Canada has been compiled by Lilian Brandt,
and published by the charity organization of New York and the N'ational
Association for the Study of Tuberculosis. Bulstr ode's Eeport (Local Govern-
ment Board, 1908) gives full details as to institutions in England.
(c) Climatic Treatment.— This, after all, is only a modification of the
TUBERCULOSIS. 355
open-air method. The first question to be decided is whether the patient is
fit to be sent from home. In many instances it is a positive liardship. A
patient with well-marked cavities, hectic fever, night sweats, and emacia-
tion is much better at home, and the physician should not be too much influ-
enced by the importunities of the sick man or his friends. The requirements
of a suitable climate are a pure atmosphere, an equable temperature not sub-
ject to rapid variations, and a maximum amount of sunshine. Given these
three factors, it makes little difference where a patient goes, so long, as he
lives an outdoor life. Major Woodruff believes that sunshine may be hurtful,
and he has collected statistics to show that tuberculosis is more prevalent and
more fatal among the dark races, who live where the sun shines the brightest.
The point is one of interest, but I do not think the case against the sun is
made out. The different climates may be grouped into the high altitudes,
the dry, warm climates, and the moist, warm climates. Among high alti-
tudes in the United States, the Colorado resorts are the most important. Of
others, those in Arizona and New Mexico have been growing rapidly. The
rarefaction of the air in high altitudes is of benefit in increasing the respira-
tory movements in pulmonary disease, but brings about in time a condition of
dilatation of the air-vesicles and a permanent increase in the size of the chest
which is a marked disadvantage when such persons attempt subsequently to
reside at the sea-level. The great advantage of these western resorts is that
they are in progressive, prosperous countries, in which a man may find means
of livelihood and live in comfort. In Europe the chief resorts at high alti-
tudes are Davos, Les Avants, and St. Moritz. Of resorts at a moderate
altitude, Asheville and the Adirondacks are the best known in America. The
Adirondack cure has become of late years quite famous. One very decided
advantage is that after arrest of the disease the patient can return to the sea-
level without any special risk. The cases most suitable for high altitudes are
those in which the disease is limited, without much cavity formation, and with-
out much emaciation. The thin, irritable patients with chronic tuberculosis
and a good deal of emphysema are better at the sea-level. The cold winter
climate seems to be of decided advantage in tuberculosis, and in the Adiron-
dacks, where the temperature falls sometimes to 30° or even more below zero,
the patients are able to lead an out-of-door life throughout the entire winter.
Of the moist, warm climates, in America Florida and the Bermudas,
in Europe the Madeira Islands, and in Great Britain Eastbourne, Bourne-
mouth, Torquay, and Falmouth are the best known. Of the dry, warm cli-
mates, Southern California in the United States is the most satisfactory.
Many of the health resorts in the Southern States, such as Aiken, Thomas-
ville, and Summerville, are delightful winter climates for tuberculous cases.
Egypt, Algiers, and the Eiviera are the most satisfactory resorts for patients
from Europe. For additional information on the subject of climate, particu-
larly in America, the reader is referred to Solly's work on the subject.
Other considerations which should influence the choice of a locality are
good accommodations and good food. Very much is said concerning the
choice of locality in the different stages of pulmonary tuberculosis, but when
the disease is limited to an apex, in a man of fairly good personal and family
history, the chances are that he may fight a winning battle if he lives out of
doors in any climate, whether high, dry and cold, or low, moist and warm.
356 SPECIFIC INFECTIOUS DISEASES.
With bilateral disease and cavity formation there is but little hope of perma-
nent cure, and the mild or warm climates are preferable.
III. Measures which, by their Local or General Action, influence
THE Tuberculous Process. — Under this heading we may consider the
specific, the dietetic, and the general medicinal treatment of tuberculosis.
(a) Specific Treatment. — The use of tuberciilin has again become popu-
lar, and the publications of Koch, von Behring, Maragliano, and Wright have
shown that in certain cases it had a definite value. This has been the posi-
tion taken by Trudeau even after the fiasco attending its introduction, and at
the Saranac Sanatorium a certain number of cases were given tuberculin in
addition to the regular treatment. L. Brown has reported on 159 of these
cases, 43 of which were in the incipient stage. In 104 advanced cases, 30 were
discharged apparently cured and 56 with the disease arrested. Of the 43
early cases, 30 were discharged apparently well and 9 with the disease arrested.
The method of Wright and Douglas has been extensively tested during the past
three years, and it is difficult yet to arrive at positive conclusions. The inde-
pendent work in England and in America appears to be against the opsonic
index as a trustworthy guide; on the other hand, in suitable cases, particu-
larly of local tuberculosis, the vaccine treatment has proved of great value.
(&) Dietetic Treatment. — The outlook in tuberculosis depends much
upon the digestion. It is rare to see recovery in a case in which there is
persistent gastric trouble, and the physician should ever bear in mind the
fact that in this disease the primcB vice control the position. The early nausea
and loss of appetite in many cases are serious obstacles. Many patients loathe
food of all kinds. A change of air or a sea voyage may promptly restore the
appetite. When either of these is impossible, and if, as is almost always the
case, fever is present, the patient should be placed at rest, kept in the open
air nearly all day, and fed at stated intervals with small quantities either of
milk, buttermilk, or koumyss, alternating if necessary with meat juice and
egg albumin. Some cases which are disturbed by eggs and milk do well on
koumyss. It may be necessary to resort to Debove's method of over-alimenta-
tion or forced feeding. The stomach is first washed out with cold water, and
then, through the tube, a mixture is given containing a litre of milk, an egg,
and 100 grammes of very finely powdered meat. This is given three times a
day. Sometimes the patients will take this mixture without the unpleasant
necessity of the stomach-tube, in which case a smaller amount may be given.
Eaw eggs are very suitable for the purpose of over-feeding, and may be taken
in the intervals between the meals. Beginning with one three times a day the
number may be increased to two, three, or even four at a time. In the Ger-
man sanatoria a very special feature is this over-feeding, even when fever is
present. E. W. Philip advises a raw meat diet — zomotherapy — ^lialf a pound
three times a day, either minced or as a soup.
In many cases the digestion is not at all disturbed and the patient can
take an ordinary diet. It is remarkable how rapidly the appetite and diges-
tion improve on the fresh-air treatment, even in cases which have to remain
in the city. Care should be taken that the medicines do not disturb the stom-
ach. Not infrequently the sweet syrups used in the cough mixtures, cod-liver
oil, creasote, and the hypophosphites produce irritation, and by interfering
with digestion do more harm than good. On the other hand, the bitter tonics.
TUBERCULOSIS. 357
with acids, and the various malt preparations are often in these cases most
satisfactory. The indications for alcohol in tuberculosis are enfeebled diges-
tion with fever, a weak heart, and rapid pulse. A routine administration is
not advisable, and there is no evidence that its persistent use promotes fibroid
processes in the tuberculous areas. In the advanced, stages, particularly when
the temperature is low between eight and ten in the morning, whisky and
milk, or whisky, egg, and milk may be given with great advantage. The red
wines are also beneficial in moderate quantities.
(c) General Medical Treatment. — Ko medicinal agents have any special
or peculiar action upon tuberculous processes. The influence which they
exert is upon the general nutrition, increasing the physiological resistance,
and rendering the tissues less susceptible to invasion. The following are
the most important remedies which seem to act in this manner :
Creasote, which may be administered in capsules, in increasing doses,
beginning with 1 minim three times a day and, if well borne, increasing the
dose to 8 or 10 minims. It may also be given in solution, with tincture of
cardamoms and alcohol. It is an old remedy, strongly recommended by
Addison, and the reports of Jaccoud, Fraentzel, and many others show that
it has a positive value in the disease. Guaiacol may be given as a substitute,
either internally or hypodermieally.
Cod-liver Oil. — In glandular and bone tuberculosis, this remedy is un-
doubtedly beneficial in improving the nutrition. In pulmonary tuberculosis
its aj3tion is less certain, and it is scarcely worthy of the unbounded confidence
which it enjoyed for so many years. It should be given in small doses, not
more than a teaspoonf ul three times a day after meals. It seems to act better
in children than in adults. Fever and gastric irritation are contraindica-
tions to its use. When it is not well borne, a dessertspoonful of rich cream
three times a day is an excellent substitute. The clotted or Devonshire cream
is preferable.
The HypopJiospJiites. — These in various forms are useful tonics, but it is
doubtful if they have any other action. They certainly exercise no specific
influence upon tubercle. They may be given in the form of the syrup of the
hypophosphites of calcium, sodium, and potassium of the U. S. P.
Arsenic. — There is no general tonic more satisfactory in cases of tuber-
culosis of all kinds than Fowler's solution. It may be given in 5-minim doses
three times a day and gradual^ increased; stopping its use whenever unpleas-
ant symptoms arise, and in any case intermitting it every third or fourth week.
Treatment by compressed air is in many cases beneflcial, and under its
use the appetite improves, there is gain in weight, and reduction of the fever.
The air may be saturated with creasote.
IV. Teeatment of Special Symptoms in Pulmonary Tubeeculosis. —
(a) The Fever. — There is no more difficult problem in practical therapeutics
than the treatment of the pyrexia of tuberculosis. The patient should be
at rest, and in the open air night and day for some weeTcs. Fever does not
contraindicate an out-of-door life, but it is well for patients with a tem-
perature above 100.5° to be at rest. For the continuous pyrexia or the remit-
tent type of the early stages, quinine, small doses of digitalis, and the salicyl-
ates may be tried; but they are uncertain and rarely reliable. Under no
circumstances is that priceless remedy, quinine, so much abused as in the
358 SPECIFIC INFECTIOUS DISEASES.
fever of tuberculosis. In large doses it has a moderate antipyretic ac-
tion, but it is just in these efficient doses that it is so apt to disturb the
stomach.
Antip}Tin and antifebrin may be used cautiously; but it is better, vhen
the fever rises above 103°, to rely upon cold sponging or the tepid bath, grad-
ually cooled. When softening has taken place and the fever assumes the char-
acteristic septic type, the problem becomes still more difficult. As shown by
Chart XII (which is not by any means an exceptional one), the p^Texia, at
this stage, lasts only for twelve or fifteen hours. As a rule there are not more
than from eight to ten hours in which the fever is high enough to demand anti-
pjTetic treatment. Sometimes antifebrin, given in 2-grain doses every hour
for three or four hours before the rise in temperature takes place, either pre-
vents entirely or limits the paroxysm. If the temperature begins to rise
between two and three in the afternoon, the antifebrin may be given at eleven,
twelve, one, and, if necessary, at two. It answers better in this way than given
in the single doses. Careful sponging of the extremities for from half an
hour to an hour during the height of the fever is useful. Quinine is of little
benefit in this t}-pe of fever ; the salicylates are of still less use.
(h) Sweating. — Atropine, in doses of gr. jy^-^, and the aromatic sid-
phuric acid in large doses, are the best remedies. "When there are cough and
nocturnal restlessness, an eighth of a grain of morphia may be given with the
atropine. Muscarin (Tii v of a 1-per-cent solution), tincture of nux vomica
(TTl xxx), picrotoxin (gr. -gV) may be tried. The patient shoidd use light flan-
nel night-dresses, as the cotton night-shirts, when soaked with perspiration,
have a very unpleasant cold, clammy feeling.
(c) The cough is a troublesome, though necessary, feature in pulmonary
tuberculosis. Unless very worrying and disturbing sleep at night, or so severe
as to produce vomiting, it is not well to attempt to restrict it. When irrita-
tive and bronchial in character, inhalations are useful, particidarly the tinc-
ture of benzoin or preparations of tar, creasote, or turpentine. The throat
should be carefully examined, as some of the most irritable and distressing
forms of cough in phthisis result from larjTigeal erosions. The distressing
nocturnal cough, which begins just as the patient gets into bed and is prepar-
ing to fall asleep, requires, as a rule, preparations of opium. Codeia, in
quarter- or half -grain doses, or the s}Tupus codeise (3 j) may be given. An
excellent combination for the nocturnal cough of phthisis is morphia (gr. J-i),
dilute hydrocyanic acid (lU ij-iij), and s3Tup of wild cherry (5 j). The spirits
of chloroform, B. P., or the mistura chloroformi, U. S. P.,' or Hoffman's ano-
d5'ne, given in whisky before going to sleep, are efficacious. Mild counter-
irritation, or the application of a hot poultice, will sometimes promptly relieve
the cough. The morning cough is often much relieved by taking Immedi-
ately after getting up a glass of hot milk or a cup of hot water, to which 15
grains of bicarbonate of soda have been added. In the later stages of the dis-
ease, when cavities have formed, the accumulated secretion must be expec-
torated and the paroxysms of coughing are now most exhausting. The seda-
tives, such as morphia and hydrocyanic acid, should be given cautiously. The
aromatic spirit of ammonia in full doses helps to allay the paroxysm."^ When
the expectoration is profuse, creasote internally, or inhalations of turpentine
and iodine, or oil of eucahT)tus, are useful. For the troublesome dysphagia
LEPROSY, 359
a strong solution of cocaine (gr. x) with boric acid (gr. v) in glycerine and
water (§ j) may be used locally.
(d) For the diarrTioRa large doses of bismuth, combined with Dover's pow-
der, and small starch enemata^, with or without opium, may be given. The
acetate of lead and opium pill often acts promptly, and the acid diarrhoea
mixture, dilute acetic acid (TIXx-xv), morphia (gr. ^), and acetate of lead
(gr, j-ij), may be tried.
(e) The treatment of the hemoptysis will be considered in the section
on haemorrhage from the lungs. Dyspnoea is rarely a prominent symptom
except in the advanced stages, when it may be very troublesome and distress-
ing. Ammonia and morphia, cautiously administered, may be used.
If the pleuritic pains are severe, the side may be strapped, or painted with
tincture of iodine. The dyspeptic symptoms require careful treatment, as
the outlook in individual cases depends much upon the condition of the stom-
ach. Small doses of calomel and soda often allay the distressing nausea of
the early stage.
A last word on this siibject to the general practitioner. The battle against
this scourge is in your hands. Much has been done, much remains to do. By
early diagnosis and prompt, systematic treatment of individual cases, by striv-
ing in every possible way to improve the social condition of the poor, by join-
ing actively in the ivorh of the local and national antituberculosis societies you
can help in the most important and the most hopeful campaign ever under-
taken by the profession.
XXXIV. LEPROSY.
Definition. — A chronic infectious disease caused by Bacillus leprcB, charac-
terized by the presence of tubercular nodules in the skin and mucous mem-
branes (tubercular leprosy) or by changes in the nerves (anaesthetic leprosy).
At first these forms may be separate, but ultimately both are combined, and
in the characteristic tubercular form there are disturbances of sensation.
History. — The disease appears to have prevailed in Egypt even so far back
as three or four thousand years before Christ. The Hebrew writers make
many references to it, but, as is evident from the description in Leviticus,
many different forms of skin diseases were embraced under the term leprosy.
Both in India and in China the affection was also known many centuries be-
fore the Christian era. The old Greek and Eoman physicians were perfectly
familiar with its manifestations. Evidence of a pre-Columbian existence of
leprosy in America has been sought in the old pieces of Peruvian pottery
representing deformities suggestive of this disease, but Ashmead denies their
significance. Throughout the middle ages leprosy prevailed extensively in
Europe, and the number of leper asylums has been estimated as at least
20,000. During the sixteenth century it gradually declined.
Geographical Distribution. — In Europe leprosy prevails in Iceland, Nor-
way and Sweden, parts of Russia, particularly about Dorpat, Eiga, and the
Caucasus, and in certain provinces of Spain and Portugal. In Great Britain
the cases are now all imported.
In the United States there are three important foci : Louisiana, in which
the disease has been known since 1785, and has of late increased. The state-
360 SPECIFIC INFECTIOUS DISEASES.
ment that it was introduced by the Acadians does not seem to me very likely,
since the records of its existence in Nova Scotia and New Brunswick do not
date back to that period. Dyer estimates that there are at least 524 cases
in the United States, a majority of them in Louisiana and Florida. In
Minnesota with the Norwegian colonists about 170 lepers are known to have
settled. The disease has steadily decreased. Bracken writes (November 2,
1904) that there are only 10 known cases of leprosy in Minnesota at present,
a gradual reduction since 1897, when there were 21; 4 of these 10 cases are
from Sweden. One of the cases is a native, born of Norwegian parents.
Bracken says there are at least two native-born lepers in the State of Miime-
sota. The Leprosy Commission (1902) of the United States collected records
of 278 cases, 145 born in the United States, 120 in foreign countries; 186
probably contracted the disease in the United States.
The few cases seen in the large cities of the Atlantic coast are imported.
In the Dominion of Canada there are foci of leprosy in two or three
coimties of New Brunswick, settled by French Canadians, and in Cape Breton,
Nova Scotia. The disease appears to have been imported from Norinandy
about the end of the 18th century. The number of cases has gradually les-
sened. Dr. A. C. Smith, the physician in charge of the lazaretto at Tracadie,
New Brunswick, reports under date of October 11, 1904, that there are 14
lepers at present under his care — 9 males and 5 females, with 2 outside soon
to be admitted. Of these, 3 are immigrant Icelanders from Manitoba; 1 is
a negro from the West India Islands. Dr. Smith states that segregation is
gradually stamping out the disease in New Brunswick. The cases have dwin-
dled from about 40 to half that number. In Cape Breton it has almost dis-
appeared. A few cases are met with among the Icelandic settlers in Mani-
toba, and with the Chinese the affection has been introduced into British
Columbia. In the various provinces of the Philippine Islands there were
reported in October, 1904, 3,803 lepers.
Leprosy is endemic in the West India Islands. It also occurs in Mexico
and throughout the Southern States. In the Sandwich Islands it spread rap-
idly after 1860, and strenuous attempts have been made to stamp it out by
segregating all lepers on the island of Molokai. In 1904 there were 856 lepers
in the settlement.
In British India, according to the Leprosy Commission, there are 100,000
lepers. This is probably a low estimate. In China leprosy prevails exten-
sively. In South Africa, it has increased rapidly. In Australia, New
Zealand, and the Australasian islands it also prevails, chiefly among the Chi-
nese. The essays of Ashburton Thompson and James Cantlie deal fully with
leprosy in China, Australia, and the Pacific islands.
Etiology. — Bacillus lepra, discovered by Hansen, of Bergen, in 1871, is
universally recognized as the cause of the disease. It has many points of re-
semblance to the tubercle bacillus, but can be readily differentiated. It is cul-
tivated with extreme difficulty, and, in fact, there is some doubt as to whether
it is capable of growth on artificial media.
Modes of Infection.— (a) hiocnl at ion. —While it is highly probable that
leprosy may be contracted by accidental inoculation, the experimental evi-
dence is as yet inconclusive. With one possible exception negative results
have followed the attempts to reproduce the disease in man. The Hawaiian
LEPROSY. 361
convict under sentence of death, who was inoculated on September 30, 1884,
by Arning, four weeks later had rheumatoid pains and gradual painful swell-
ing of the ulnar and median nerves. The neuritis gradually subsided, but
there developed a small lepra tubercle at the site of the inoculation. In 1887
the disease was quite manifest, and the man died of it six years after inocula-
tion. The case is not regarded as conclusive, as he had leprous relatives and
lived in a leprous country.
(&) Heredity. — For years it was thought that the disease was transmitted
from parent to child, but the general opinion, as expressed in the recent
Leprosy Congress in Berlin, was decidedly against this view. Of course, the
possibility of its transmission can not be denied, and in this respect leprosy
and tuberculosis occupy very much the same position, though men with very
wide experience have never seen a new-born leper. The youngest cases are
rarely under three or four years of age.
(c) By Contagion. — The bacilli are given off from the open sores; they
are found in the saliva and expectoration in the cases with leprous lesions
in the mouth and throat, and occur in very large numbers in the nasal secre-
tion. Sticker found in 153 lepers, subjects of both forms of the disease,
bacilli in the nasal secretion in 128, and herein, he thinks, lies the chief
source of danger. Schaffer was able to collect lepra bacilli on clean slides
placed on tables and floors near to lepers whom he had caused to read aloud.
The bacilli have also been isolated from the urine and the milk of patients.
It seems probable that they may enter the body in many ways through the
mucous membranes and through the skin. Sticker believes that the initial
lesion is in an ulcer above the cartilaginous part of the nasal septum. One
of the most striking examples of the contagiousness of leprosy is the follow-
ing: "In 1860, a girl who had hitherto lived at Holstfershof, where no
leprosy existed, married and went to live at Tarwast with her mother-in-law,
who was a leper. She remained healthy, but her three children (1, 2, 3)
became leprous, as also her younger sister (4), who came on a visit to Tar-
wast and slept with the children. The younger sister developed leprosy after
returning to Holstfershof. At the latter place a man (5), fifty- two years old,
who married one of the ' younger sister's ' children, acquired leprosy ; also a
relative (6), thirty-six years old, a tailor by occupation, who frequented the
house, and his wife (7), who came from a place where no leprosy existed.
The two men last mentioned are at present (1897) inmates of the leper
asylum at Dorpat." There is certain evidence to show that the disease may
be spread through infected clothing, and the high percentage of washerwomen
among lepers is also suggestive.
Conditions influencing Infection. — The disease attacks persons of all
ages. We do not yet understand all the conditions necessary. Evidently
the closest and most intimate contact is essential. The doctors, nurses, and
Sisters of Charity who care for the patients are very rarely attacked. In the
lazaretto at Tracadie not one of the Sisters who for -more than forty years
have so faithfully nursed the lepers has contracted the disease. Father
Damian, in the Sandwich Islands, and Father Boglioli, in Few Orleans,
both fell victims in the discharge of their priestly duties. There has long
been an idea that possibly the disease may be associated with some special
kind of food, and Jonathan Hutchinson believes that a fish diet is the tertium
25
362 SPECIFIC INFECTIOUS DISEASES.
quid, which either renders the patient susceptible or with which the poison
may be taken.
Morbid Anatomy. — The leprosy tubercles consist of granulomatous tissue
made up of cells of various sizes in a connective-tissue matrix. The bacilli
in extraordinary numbers lie partly between and partly in the cells. The
process gradually involves the skin, giving rise to tuberous outgrowths with
intervening areas of ulceration or cicatrization, which in the face may grad-
ually produce the so-called fades leontina. The mucous membranes, particu-
larly the conjunctiva, the cornea, and the larynx may gradually be involved.
In many cases deep ulcers form which result in extensive loss of substance
or loss of fingers or toes, the so-called lepra mutilans. In anesthetic leprosy
there is a peripheral neuritis due to the development of the bacilli in the nerve-
fibres. Indeed, this involvement of the nerves plays a primary part in the
etiology of many of the important features, particularly the trophic changes
in the skin and the disturbances of sensation.
Clinical Forms. — (a) Tubercular Leprosy. — Prior to the appearance
of the nodules there are areas of cutaneous erythema which may be sharply
defined and often hypergesthetic. This is sometimes known as macular
leprosy. The affected spots in time become pigmented. In some instances
this superficial change continues without the development of nodules, the areas
become angesthetic, the pigment gradually disappears, and the skin gets per-
fectly white — the lepra alia. Among the patients at Tracadie it was particu-
larly interesting to see three or four in this early stage presenting on the face
and forearms a patchy erythema with slight swelling of the skin. The diag-
nosis of the condition is perfectly clear, though it may be a long time before
any other than sensory changes develop. The eyelashes and eyebrows and the
hairs on the face fall out. The mucous membranes finally become involved,
particular!}^ of the mouth, throat, and larynx; the voice becomes harsh and
finally aphonic. Death results not infrequently from the laryngeal compli-
cations and aspiration pneumonia. The conjunctivae are frequently attacked,
and the sight is lost by a leprous keratitis.
(&) Anesthetic Leprosy. — This remarkable form has, in characteristic
cases, no external resemblance whatever to the other variety. It usually
begins with pains in the limbs and areas of hypersesthesia or of numbness.
Very early there may be trophic changes, seen in the formation of small bullae
(Hillis). Maculge appear upon the trunk and extremities, and after persist-
ing for a variable time gradually disappear, leaving areas of anaesthesia, but
the loss of sensation may come on independently of the outbreak of maculae.
The nerve-trunks, where superficial, may be felt to be large and nodular. The
trophic disturbances are usually marked. Pemphigus-like bullae develop in
the affected areas, which break and leave ulcers which may be very destructive.
The fingers and toes are liable to contractures and to necrosis, so that in
chronic cases the phalanges are lost. The course of angesthetic leprosy is
extraordinarily chronic and may persist for years without leading to much
deformity. One of the most prominent clergymen on this continent had anaes-
thetic leprosy for more than thirty years, which did not seriously interfere
with his usefulness, and not in the slightest with his career.
Diagnosis. — Even in the early stage the duslcy erythematous maculae with
hypersesthesia or areas of anaesthesia are very characteristic. In an advanced
INFECTIOUS DISEASES OF DOUBTFUL NATURE. 363
grade neither the tubercular nor anaesthetic forms could possibly be mistaken
for any other afEection. In a doubtful case the microscopical examination of
an excised nodule is decisive.
Treatment. — There are no specific remedies in the disease. The gurjun
and chaulmoogra oils have been recommended, the former in doses of from
5 to 10 minims, the latter in 2-drachm doses. Calmette's antivenene, 20 to
30 c. c, subcutaneously, has been followed by remarkable results in a few cases.
Segregation should be compulsory in all cases except where the friends can
show that they have ample provision in their own home for the complete isola-
tion and proper care of the patient.
XXXV. INFECTIOUS DISEASES OF DOUBTFUL
NATURE.
(1) Febricula — Ephemeral Fever,
Definition. — Fever of slight duration, probably depending upon a variety
of causes.
A febrile paroxysm lasting for twenty-four hours and disappearing com-
pletely is spoken of as ephemeral fever. If it persists for three, four, or
more days without local afEection it is referred to as febricula.
The cases may be divided into several groups:
(a) Those which represent mild or abortive types of the infectious dis-
eases. It is not very unusual, during an epidemic of typhoid, scarlet fever,
or measles, to see cases with some of the prodromal symptoms and slight fever,
which persist for two or three days without any distinctive features. I have
already spoken of these in connection with the abortive type of typhoid fever.
Possibly, as Kahler suggests, some of the cases of transient fever are due to
the rheumatic poison.
(&) In a larger and perhaps more important group of cases the symp-
toms develop with dyspepsia. In children indigestion and gastro-intestinal
catarrh are often accompanied by fever. Possibly some instances of longer
duration may be due to the absorption of certain toxic substances. Slight
fever has been known to follow the eating of decomposing substances or the
drinking of stale beer; but the gastric juice has remarkable antiseptic prop-
erties, and the frequency with which persons take from choice articles which
are " high," shows that poisoning is not likely to occur imless there is existing
gastro-intestinal disturbance.
(c) Cases which follow exposure to foul odors or sewer-gas. That a
febrile paroxysm may follow a prolonged exposure to noxious odors has long
been recognized. The cases which have been described under this heading
are of two kinds: an acute severe form with nausea, vomiting, colic, and
fever, followed perhaps by a condition of collapse or coma; secondly, a form
of low fever with or without chills. A good deal of doubt still exists in
the minds of the profession about these cases of so-called sewer-gas poison-
ing. It is a notorious fact that workers in sewers are remarkably free from
disease, and in many of the cases which have been reported the illness may
have been only a coincidence. There are instances in which persons have
been taken ill with vomiting and slight fever after exposure to the odor of a
364 SPECIFIC INFECTIOUS DISEASES.
very offensive post mortem. Whether true or not, the idea is firmly implanted
in the minds of the laity that very powerful odors from decomposing matters
may produce sickness.
(d) Many cases doubtless depend upon slight unrecognized lesions, such as
tonsillitis or occasionally an abortive or larval pneumonia. Children are
much more frequently affected than adults.
The symptoms set in, as a rule, abruptlj'-, though in some instances there
may have been preliminary tnalaise and indisposition. Headache, loss of
appetite, and furred tongue are present. The urine is scanty and high-colored,
the fever ranges from 101° to 103°, sometimes in children it rises higher.
The cheeks may be flushed and the patient has the outward manifestations of
fever. In children there may be bronchial catarrh with slight cough.
Herpes on the lips is a common symptom. Occasionally in children the cere-
bral symptoms are marked at the outset, and there may be irritation, restless-
ness, and nocturnal delirium. The fever terminates abruptly by crisis from
the second to the fourth day; in some instances it may continue for a week.
The diagnosis generally rests upon the absence of local manifestations,
particularly the characteristic skin rashes of the eruptive fevers, and most
important of all the rapid disappearance of the pyrexia. The cases most
readily recognized are those with acute gastro-intestinal disturbance.
The treatment is that of mild pyrexia — rest in bed, a laxative, and a fever
mixture containing nitrate of potassium and sweet spirits of nitre.
(2) IisTFECTious Jaundice.
Epidemic Catarrhal Jaundice {WeiVs Disease).
Local and wide-spread outbreaks of jaundice have been known for years.
Three or four cases may occur in one house, or many persons in an institu-
tion are attacked, or the disease becomes wide-spread in a community. In
Great Britain this epidemic form is rare. In the United States many out-
breaks have occurred. It prevailed extensively in North Carolina in 1899-
1900, and a fatal case of that epidemic came under my observation. In Syria,
in Greece, in Egypt (Sandwith), in India (S. Anderson), and in South Africa
during the Boer war (H. B. Matheas), epidemics have been described. It
has prevailed most frequently in the summer months. The symptoms are at
first gastric, then fever follows (with the usual concomitants) and jaundice,
which may be slight or very intense, and as a rule albuminuria. The liver
and spleen enlarge, and in severe forms there are nervous symptoms and
haemorrhages. There is often a secondary fever. The attack lasts from ten
days to three weeks. The course is nsually favorable ; fatal cases are rare in
the United States and in India and South Africa, but in the Greek Hospital
at Alexandria the death-rate was 32 among 300 cases (Sandwith).
In 1886 Weil described a disease characterized by the features just men-
tioned, but the cases occurred in groups, and a very large proportion in
butchers. It is probable there are several types of acute infectious jaundice.
The etiology is unknown. The proteus has been described in connection with
Weil's disease. In the fatal case from North Carolina the autopsy threw no
light on the nature of the disease. The proteus was isolated from the liver
and kidney, and four other organisms from various parts. It is possible that
INFECTIOUS DISEASES OF DOUBTFUL NATURE. 365
acute catarrhal jaimdice is a mild infection, representing the sporadic form
of the disease.
(3) Milk-Sickness.
This remarkable disease prevails in certain districts of the United States,
west of the Alleghany Mountains, and is connected with the affection in cat-
tle known as the trembles. It prevailed extensively in the early settlements
in certain of the Western States and proved very fatal. The general opinion
is that it is communicated to man only by eating the flesh or drinking the
milk of diseased animals. The butter and cheese are also poisonous. In ani-
mals, cattle and the young of horses and slieep are most susceptible. It is
stated that cows giving milk do not themselves show marked symptoms unless
driven rapidly, and, according to Graff, the secretion may be infective when
the disease is latent. When a cow is very ill, food is refused, the eyes are
injected, the animal staggers, the entire muscular system trembles, and death
occurs in convulsions, sometimes with great suddenness. The disease is most
frequent in new settlements.
In man the symptoms are those of a more or less acute intoxication. After
a few days of uneasiness and distress the patient is seized with pains in the
stomach, nausea and vomiting, fever and intense thirst. There is usually
obstinate constipation. The tongue is swollen and tremulous, the breath is
extremely foul and, according to Graff, is as characteristic of the disease as
is the odor in small-pox. Cerebral symptoms — restlessness, irritability, coma,
and convulsions — are sometimes marked, and there may gradually be produced
a typhoid state in which the patient dies.
The duration of the disease is variable. In the most acute form death
occurs within two or three days. It may last for ten days, or even for three
or four weeks. Graff states that insanity occurred in one case. The poisonous
nature of the flesh and of the milk has been demonstrated experimentally.
An ounce of butter or cheese, or four ounces of the beef, raw or boiled, given
three times a day, will kill a dog within six days. Fortunately, the disease
has become rare. No definite pathological lesions are known. Jordan and
Harris have studied a Kew-Mexico epidemic (1908) and have found a bacillus
{B. lactimorhi) with cultures of which the disease may be reproduced in other
animals.
(4) Glandular Fever.
Definition. — An infectious disease of children, developing, as a rule, with-
out premonitory signs, and characterized by slight redness of the throat, high
fever, swelling and tenderness of the lymph-glands of the neck, particularly
those behind the sterno-cleido-mastoid muscles. The fever is of short dura-
tion, but the enlargement of the glands persists for from ten days to three
weeks.
In children acute adenitis of the cervical and other glands with fever has
been noted by many observers, but Pfeiffer in 1889 called special attention
to it under the name of Druesenfieher. He described it as an infectious dis-
ease of young children between the ages of five and eight years, characterized
by the above-mentioned symptoms. Since Pfeiffer's paper a good deal of work
has been done in connection with the subject, and in the United States West
366 SPECIFIC INFECTIOUS DISEASES.
and Hamill, and in England Dawson Williams^, have more particularly empha-
sized the condition.
Etiology. — It may occur in epidemic form. West, of Bellaire, Ohio,
describes an ejjideniic of 96 cases in children between the ages of seven months
and thirteen years. Bilateral swelling of the carotid lymph-glands was a most
marked feature. In three-fourths of the cases the post-cervical, inguinal, and
axillary glands were involved. The mesenteric glands were felt in 37 cases,
the spleen was enlarged in 57, and the liver in 87 cases. Coryza was not pres-
ent, and there were no bronchial or pulmonary symptoms. Cases occurred
between the months of October and June. The nature of the infection has
not been determined.
Symptoms. — The onset is sudden and the first complaint is of pain on
moving the head and neck. There may be nausea and vomiting and abdomi-
nal pain. The temperature ranges from 101° to 103°. . The tonsils may be
a little red and the lymphatic tissues swollen, but the throat symptoms are
quite transient and unimportant. On the second or third day the enlarged
glands appear, and during the course they vary in size from a pea to a goose-
egg. They are painful to the touch, but there is rarely any redness or swell-
ing of the skin, though at times there is some puffiness of the subcutaneous
tissues of the neck, and there may be a little difficulty in swallowing. In
some instances there has been discomfort in the chest and a paroxysmal cough,
indicating involvement of the tracheal and bronchial glands. The swelling
of the glands persists for from two to three weeks. Among the serious fea-
tures of the disease are the termination of the adenitis in suppuration, which
seems rare (though Neumann has met with it in 13 cases), and hemorrhagic
nephritis. Acute otitis media and retro-pharyngeal abscess have also been
reported.
The outlook is favorable. West suggests the use of small doses of calomel
during the height of the trouble.
(5) Mountain Fever — Mountain Sickness.
Several distinct diseases have been described as mountain fever. An im-
portant group, the mountain anaemia, is associated with the anJcylostoma. A
second group of cases belongs to typhoid fever; and instances of this disease
occurring in mountainous regions in the Western States are referred to as
mountain fever. The observations of Hoff and Smart, and more recently of
Woodruff and of Eajnuond, show that the disease is typhoid fever.
C. E. AVoodrufP, of the United States Army, has reported a group of 35
cases at Fort Custer, which, as he says, would certainly have been described
as mountain fever, but in which the clinical features and the Widal reaction
showed there was no question that they were typhoid. It would be well, I
thmk, for the use of the term mountain fever to be discontinued.
Mountain sichiess comprises the remarkable group of phenomena which
develop m very high altitudes. The condition has been very accurately de-
scribed by Mr. WhAonper. In the ascent of Chimborazo they were first
affected at a height of 16,664 feet. The symptoms were severe headache,
gaspmg for breath, parched throat, intense thirst, loss of appetite, and an
mtense malaise. Mr. Whymper's temperature was 100.4°. The symptoms in
INFECTIOUS DISEASES OF DOUBTFUL NATURE. 367
his case lasted nearly three days. In a less aggravated form such symptoms
may present themselves at much lower levels. A very full description is given
by Allbutt in vol. iii of his System.
(6) Miliary Fever — Sweating Sickness,
The disease is characterized by fever, profuse sweats, and an eruption of
miliary vesicles. It prevailed and was very fatal in England in the fifteenth
and sixteenth centuries, and was made the subject of an important memoir
by Johannes Caius, 1552. Of late years it has been confined entirely to cer-
tain districts in France (Picardy) and Italy. An epidemic of some extent
occurred in France in 1887. Hirsch gives a chronological account of 194
epidemics between 1718 and 1879, many of which were limited to a single
village or to a few localities. Occasionally the disease has become widely
spread. Slight epidemics have occurred in Germany and Switzerland. Within
the past few years there have been several small outbreaks in Austria. They
are usually of short duration, lasting only for three or four weeks — sometimes
not more than seven or eight days. As in infiuenza, a very large number of
persons are attacked in rapid succession. In the mild cases there is only slight
fever, with loss of appetite, and erythematous eruption, profuse perspiration,
and an outbreak of miliary vesicles. The severe cases present the symptoms
of intense infection — delirium, high fever, profound prostration, and haemor-
rhage. The death-rate at the outset of the disease is usually high, and, as
is so graphically described in the account of some of the epidemics of the
middle ages, death may occur in a few hours. The most recent and the full-
est account of the disease is given in Nothnagel's Ilandbuch by Immermann,
(7) foot-and-mouth disease — epidemic stomatitis — aphthous
Fever.
Foot-and-mouth disease is an acute infectious disorder met with chiefly
in cattle, sheep, and pigs, but attacking other domestic animals. It is of
extraordinary activity, and spreads with " lightning rapidity " over vast terri-
tories, causing very serious losses. In cattle, after a period of incubation of
three or five days, the animal gets feverish, the mucous membrane of the
mouth swells, and little grayish vesicles the size of a hemp seed begin to de-
velop on the edges and lower portion of the tongue, on the gums, and on the
mucous membrane of the lips. They contain at first a clear fluid, which
becomes turbid, and then they enlarge and gradually become converted into
superficial ulcers. There is ptyalism, and the animals lose flesh rapidly. In
the cow the disease is also frequently seen about the udder and teats, and the
milk becomes yellowish-white in color and of a mucoid consistency.
The transmission to man is by no means uncommon, and several impor-
tant epidemics have been studied in the neighborhood of Berlin. In Zuill's
translation of Friedberger and Frohner's Pathology and Therapeutics of
Domestic Animals (Philadelphia, 1895) the disease is thus described: "In
man the symptoms are: fever, digestive troubles, and vesicular eruption upon
the lips, the buccal and pharyngeal mucous membranes (angina). The dis-
ease does not seem to be transmissible through the meat of diseased animals."
In wide-spread epidemics there has been sometimes a marked tendency
368 SPECIFIC INFECTIOUS DISEASES.
to hsemorrhages. The disease nins, as a rule, a favorable course, but in
Siegel's report of an epidemic the mortality was 8 per cent.
Wlien epidemics are prevailing in cattle the milk should be boiled, and
the proper prophylactic measures taken to isolate both the cattle and the
individuals who come in contact with them.
(8) Psittacosis.
A disease in birds, characterized by loss of appetite, weakness, diarrhoea,
convulsions, and death. In Germany, France, and Italy a disease in man
characterized by an atj^Dical pneumonia, great weakness and depression, and
signs of a profound infection has been ascribed to contagion from birds, par-
ticularly parrots. There have usually been house epidemics with a very high
rate of mortality. A few cases have been reported in England, and Vickery, of
Boston, has reported three probable cases. The bacteriolog}' is still doubtful.
(9) EocKT Mountain Spotted Fever. Tick Fever.
In the Bitter-root A'alley of Montana and in the mountains of Idaho,
jSTevada, and Wyoming there is an acute infection characterized by chill, fever,
pains in back and bones, and a macular rash, becoming liEemorrhagic. It was
reported upon occasionally by army surgeons — e. g., Wood, but nothing defi-
nite was known until the careful studies of Wilson and Chowning (1902), who
described a piroplasma in the blood, and believed the disease to be transmitted
by ticks. This latter point has been confirmed, but the existence of the piro-
plasma is doubtful. The studies of King and Eicketts have demonstrated
beyond doubt the transmission of the disease by the tick, Dermacentor occi-
dentalis, but the true parasite has not been determined. The disease is readily
given to the guinea-pig and monkey, and is transmissible from one animal to
another by the bite of the tick. Immunity is given by an attack, and in ani-
mals this is transmitted to the young. After an incubation of from three to
ten days the disease begins with a chill, fever, and severe pains in the limbs.
The rash appears from the second to the seventh day, is macular, dark, and
becomes hfemorrhagic. Illustrations of it show a rash not unlike that of
tj^jhus. The skin is often swollen. Haemorrhages from the mucous mem-
branes are not uncommon. The temperature range is from 103° to 105°, and
at the height of the disease there is delirium and stupor. Convalescence begins
in the fourth week. The death-rate is high for an eruptive fever, reaching 70
per cent in Montana, but in Idaho it is not more than 3 or 3 per cent. The
treatment is that of an acute infection.
(10) SwiXE Fever.
A few cases have been described from accidental inoculation in the prepara-
tion of cultures and in making post mortems upon pigs. In the course of from
twelve hours to three days there is swelling of the fingers of the affected hand,
which have a blue-red color, and small nodules form. In some of the instances
the course has been like that of a painful erythema migrans, with swelling of
the l}Tnph-glands. A specific serum has been used with success in several
cases.
SECTION III.
THE INTOXIOATIOI^S
AND SUN-STROKE.
I. ALCOHOLISM.
(1) Acute Alcoholism. — When a large quantity of alcohol is taken, the
influence is chiefly on the nervous system, and is manifested in muscular inco-
ordination, mental disturbance, and, finally, narcosis. The individual pre-
sents a flushed, sometimes slightly cyanosed face, the pulse is full, respira-
tions deep but rarely stertorous. The pupils are dilated. The temperature
is frequently below normal, particularly if the patient has been exposed to
cold. Perhaps the lowest reported temperatures have been in cases of this
sort. An instance is on record in which the patient on admission to hospital
had a temperature of 34° C. (ca. 75° F.), and ten hours later the temperature
had not risen to 91°. The unconsciousness is rarely so deep that the patient
can not be roused to some extent, and in reply to questions he mutters inco-
herently. Muscular twitchings may occur, but rarely convulsions. The
breath has a heavy alcoholic odor. The respirations may be very slow; in
a recent case they were only six in the minute.
The diagnosis is not difficult, yet mistakes are frequently made. Per-
sons are sometimes brought to hospital by the police supposed to be drunk
when in reality they are dying from apoplexy. Too great care can not be exer-
cised, and the patient should receive the benefit of the doubt. In some in-
stances the mistake has arisen from the fact that a person who has been drink-
ing heavily has been stricken with apoplexy. In this condition the coma is
usually deeper, stertor is present, and there may be evidence of hemiplegia in
the greater flaccidity of the limbs on one side. The subject will be considered
in the section upon ursemic coma.
Dipsomania is a form of acute alcoholism seen in persons with a strong
hereditary tendency to drink. Periodically the victims go " on a spree," but
in the intervals they are entirely free from any craving for alcohol.
(2) Chronic Alcoholism. — In moderation, wine, beer, and spirits may be
taken throughout a long life without impairing the general health.
According to Fajne, the poisonous efi^ects of alcohol are manifested (1)
as a functional poison, as in acute narcosis; (2) as a tissue poison, in which
its effects are seen on the parenchymatous elements, particularly epithelium
and nerve, producing a slow degeneration, and on the blood-vessels, causing
thickening and ultimately fibroid changes; and (3) as a checker of tissue
369
370 THE INTOXICATIONS AND SUN-STROKE.
oxidation, since the alcohol is consumed in place of the fat. This leads to
fatty changes and sometimes to a condition of general steatosis.
The chief effects of chronic alcohol poisoning may be thus summarized.
Nervous System. — Functional disturbance is common. Unsteadiness of
the muscles in performing any action is a constant feature. The tremor is
best seen in the hands and in the tongue. The mental processes may be dull,
particularly in the early morning hours, and the patient is unable to transact
any business until he has had his accustomed stimulant. Irritability of tem-
per, forgetfulness, and a change in the moral character of the individual
gradually come on. The judgment is seriously impaired, the will enfeebled,
and in the final stages dementia may supervene. An interesting combina-
tion of symptoms in chronic alcoholics is characterized by peripheral neuritis,
loss of memory, and pseudo-reminiscences — that is, false notions as to the
patient's position in time and space, and fabulous explanations of real occur-
rences. The peripheral neuritis is not always present; there may be only
tremor and jactitation of the lips, and thickness of the speech, with visual hal-
lucinations. The mental condition was described by Jackson and by Wilks.
Korsakoff speaks of it as a psychosis polyneuritica, and the symptom-complex
is sometimes called by his name. The relation of chronic alcoholism to insan-
ity has been much discussed. According to Savage, of 4,000 patients admitted
to the Bethlehem Hospital, 133 gave drink as the cause of their insanity.
Chronic alcoholism is certainly one of the important elements in the strain
which leads to mental breakdown. Epilepsy may result directly from chronic
drinking. It is a hopeful form, and may disappear entirely with a return to
habits of temperance.
There is a remarkable condition in chronic alcoholics of which I have seen
at least half a dozen cases. A heavy drinker, who may perhaps have had
attacks of delirium tremens, begins to get drowsy or a little more befuddled
than usual ; gradually the stupor deepens until he becomes comatose, in which
state he may remain for weeks. There may be slight fever, but there are
no signs of paralysis, and no optic neuritis. The urine may be normal. The
lumbar puncture yields a clear fluid, but under high pressure. In one case,
which died at the end of six weeks, there were the anatomical features of a
serous meningitis.
No characteristic changes are found in the nervous system. Hsemorrhagic
pach}Tneningitis is not very rmcommon. Opacity and thickening of the pia-
arachnoid membranes, with more or less wasting of the convolutions, gen-
erally occur. These are in no way peculiar to chronic alcoholism, but are
found in old persons and in chronic wasting diseases. In the very protracted
cases there may be chronic encephalo-meningitis with adhesions of the mem-
branes. Finer changes in the nerve-cells, their processes, and the neuroglia
have been described by Berkley, Hoch, and others. By far the most striking
effect of alcohol on the nervous system is the production of the alcoholic
neuritis, which will be considered later.
Digestive System. — Catarrh of the stomach is the most common symptom.
The toper has a furred tongue, heavy breath, and in the morning a sensation
of sinking at the stomach until he has had his dram. The appetite is usu-
ally impaired and the bowels are constipated. In beer-drinkers dilatation of
the stomach is common.
ALCOHOLISM. 371
Alcohol produces definite changes in the liver, leading ultimately to the
various forms of cirrhosis, to be described. In Welch's laboratory J. Frieden-
wald has caused typical cirrhosis in rabbits by the administration of alcohol.
The effect is probably a primary degenerative change in the liver-cells,
although many good observers still hold that the poison acts first upon the
connective-tissue elements. It is probable that a special vulnerability of the
liver-cells is necessary in the etiology of alcoholic cirrhosis. There are cases
in which comparatively moderate drinking for a few years has been followed
by cirrhosis; on the other hand, the livers of persons who have been steady
drinkers for thirty or forty years may show only a moderate grade of sclero-
sis. For years before cirrhosis develops heavy drinkers may present an en-
larged and tender liver, with at times swelling of the spleen. With the gas-
tric and hepatic disorders the facies often becomes very characteristic. The
venules of the cheeks and nose are dilated; the latter becomes enlarged, red,
and may present the condition known as acne rosacea. The eyes are watery,
the conjunctiva hyperaemic and sometimes bile-tinged.
The heart and arteries in chronic topers show important degenerative
changes. Alcoholism is one of the special factors in causing arterio-sclerosis.
Steell has pointed out the frequency of cardiac dilatation in these cases.
Kidneys. — The influence of chronic alcoholism upon these organs is by no
means so marked. According to Dickinson the total of renal disease is not
greater in the drinking class, and he holds that the effect of alcohol on the
kidneys has been much . overrated. Formad has directed attention to the fact
that in a large proportion of chronic alcoholics the kidneys are increased in
size. The Guy's Hospital statistics support this statement, and Pitt notes that
in 43 per cent of the bodies of hard drinkers the kidneys were hypertrophied
without showing morbid change. The typical granular kidney seems to result
indirectly from alcohol through the arterial changes.
It was formerly thought that alcohol was in some way antagonistic to
tuberculous disease, but the observations of late years indicate clearly that
the reverse is the case and that chronic drinkers are much more liable to
both acute and pulmonary tuberculosis. It is probably altogether a ques-
tion of altered tissue-soil, the alcohol lowering the vitality and enabling the
bacilli more readily to develop and grow.
(3) Delirium tremens {mania a potu) is really only an incident in the
history of chronic alcoholism, and results from the long-continued action
of the poison on the brain. The condition was first accurately described early
in the 19th century by Sutton, of Greenwich, who had numerous opportunities
for studying the different forms among the sailors. One of the most thor-
ough and careful studies of the disease was made by Ware, of Boston. A
spree in a temperate person, no matter how prolonged, is rarely if ever fol-
lowed by delirium tremens; but in the case of an habitual drinker a tem-
porary excess is apt to bring on an attack. It sometimes follows in conse-
quence of the sudden withdrawal of the alcohol. There are circumstances
which in a heavy drinker determine, sometimes with abruptness, the onset of
delirium. Such are an accident, a sudden fright or shock, and an acute in-
flammation, particularly pneumonia. It is especially apt to occur in drinkers
admitted to hospitals for injuries, especially fractures, and as this seems
most likely to occur when the alcohol is withdrawn, it is well to give such
372 THE INTOXICATIONS AND SUN-STROKE.
patients a moderate amount of alcohol. At the outset of the attack the patient
is restless and depressed and sleeps badly, symptoms which cause him to take
alcohol more freely. After a day or two the characteristic delirium sets in.
The patient talks constantly and incoherently; he is incessantly in motion,
and desires to go out and attend to some imaginary business. Hallucinations
of sight and hearing develop. He sees objects in the room, such as rats,
mice, or snakes, and fancies that they are crawling over his body. The terror
inspired by these imaginary objects is great, and has given the popular name
" horrors '' to the disease. The patients need to be watched constantly, for
in their delusions they may jump out of the window or escape. Auditory
hallucinations are not so common, but the patient may complain of hearing
the roar of animals or the threats of imaginary enemies. There is much mus-
cular tremor; the tongue is covered with a thick white fur, and when pro-
truded is tremulous. The pulse is soft, rapid, and readily compressed. There
is usually fever, but the temperature rarely registers above 102° or 103°. In
fatal cases it may be higher. Insomnia is a constant feature. On the third
or fourth day in favorable cases the restlessness abates, the patient sleeps,
and improvement gradually sets in. The tremor persists for some days, the
hallucinations gradually disappear, and the appetite returns. In more serious
cases the insomnia persists, the delirium is incessant, the pulse becomes more
frequent and feeble, the tongue dry, the prostration extreme, and death takes
place from gradual heart-failure.
Diagnosis. — The clinical picture of the disease can scarcely be confounded
with any other. Cases with fever, however, may be mistaken for meningitis.
By far the most common error is to overlook some local disease, such as pneu-
monia or erysipelas, or an accident, as a fractured rib, which in a chronic
drinker may precipitate an attack of delirium tremens. In every instance a
careful examination should be made, particularly of the lungs. It is to be
remembered that in the severer forms, particularly the febrile cases, conges-
tion of the bases of the lungs is by no means uncommon. Another point to
be borne in mind is the fact that pneumonia of the apex is apt to be accom-
panied by delirium similar to mania a potu.
Prognosis. — ^Eecovery takes place in a large proportion of the cases in pri-
vate practice. In hospital practice, particularly in the large city hospitals
to which the debilitated patients are taken, the death-rate is higher. Gerhard
states that of 1,341 cases admitted to the Philadelphia Hospital 121 proved
fatal. Eecurrence is frequent, almost indeed the rule, if the drinking is
kept up.
Treatment. — Acute alcoholism rarely requires any special measures, as the
patient sleeps off the effects of the debauch. In the case of profound alco-
holic coma it may be advisable to wash out the stomach, and if collapse symp-
toms occur the limbs should be rubbed and hot applications made to the body.
Should convulsions supervene, chloroform may be carefully administered. In
the acute, violent alcoholic mania the hypodermic injection of apomorphia,
one-eighth or one-sixth of a grain, is usually very effectual, causing nausea
and vomiting, and rapid disappearance of the maniacal symptoms.
Chronic alcoholism is a condition very difficult to treat, and once fully
established the habit is rarely abandoned. The most obstinate cases are those
with marked hereditary tendency. Withdrawal of the alcohol is the first
MORPHIA HABIT. 373
essential. This is most effectually accomplished by placing the patient in
an institution, in which he can be carefully watched during the trying period
of the first week or ten days of abstention. The absence of temptation in
institution life is of special advantage. For the sleeplessness the bromides
or hyoscine may be employed. Quinine and strychnine in tonic doses may
be given. Cocaine or the fluid extract of coca has been recommended as a sub-
stitute for alcohol, but it is not of much service. Prolonged seclusion in a
suitable institution is in reality the only efliectual means of cure. When an
hereditary tendency exists a lapse into the drinking habit is almost inevitable.
In delirium tremens the patient should be confined to bed and carefully
watched night and day. The danger of escape in these cases is very great, as
the patient imagines himself pursued by enemies or demons. Flint mentions
the case of a man who escaped in his night-clothes and ran barefooted for
fifteen miles on the frozen ground before he was overtaken. The patient
should not be strapped in bed, as this aggravates the delirium; sometimes,
however, it may be necessary, in which case a sheet tied across the bed may
be sufficient, and this is certainly better than violent restraint by three or four
men. Alcohol should be withdrawn at once unless the pulse is feeble.
Delirium tremens is a disease which, in a large majority of cases, runs a
course very slightly influenced by medicine. The indications for treatment
are to procure sleep and to support the strength. In mild cases half a drachm
of bromide of potassium combined with tincture of capsicum may be given
every three hours. Chloral is often of great service, and may be given with-
out hesitation unless the heart's action is feeble. Good results sometimes
follow the hypodermic use of hyoscine, one one-hundredth of a grain. Opium
must be used cautiously, A special merit of Ware's work was the demon-
stration that on a rational or expectant plan of treatment the percentage of
recoveries was greater than with the indiscriminate use of sedatives, which
had been in vogue for many years. When opium is indicated it should be
given as morphia, hypodermically. The effect should be carefully watched,
and if after three or four quarter-grain doses have been given the patient is
still restless and excited, it is best not to push it farther. Eepeated doses of
trional (grs. xv-xx) every four hours may be tried. Lamber advises ergotin
hypodermically in both the acute and chronic alcoholism. When fever is
present the tranquilizing effects of a cold douche or cold bath may be tried, or
the cold or warm packs. The large doses of digitalis formerly employed are
not advisable.
Careful feeding is the most important element in the treatment of these
cases. Milk and concentrated broths should be given at stated intervals. If
the pulse becomes rapid and shows signs of flagging alcohol may be given in
combination with the aromatic spirits of ammonia.
II. MORPHIA HABIT (Morphinomania ; Morphinism).
Taken at first to allay pain, a craving for the drug is gradually engendered,
and the habit in this way acquired. The effects of the constant use of opium
vary very much. In the East, where opium-smoking is as common as tobacco-
smoking with us, the ill effects are, according to good observers, not very
striking. Taken as morphia, and hypodermically, as is the rule, it is very
374 THE INTOXICATIONS AND SUN-STROKE.
injurious, but a moderate amount may be taken for years without serious
damage.
The habit is particularly prevalent among women and physicians who use
the hypodermic syringe for the alleviation of pain, as in neuralgia or sciatica.
The acquisition of the habit as a pure luxury is rare in this country.
Symptoms. — The symptoms at first are slight, and for months there may be
no disturbance of health. There are exceptional instances in which for a period
of years excessive amounts have been taken without deterioration of the mental
or bodily functions. As a rule, the dose necessary to obtain the desired sensa-
tion has gradually to be increased. As the effects wear off the victim expe-
riences sensations of lassitude and mental depression, accompanied often with
slight nausea and epigastric distress, or even recurring colic, which may be mis-
taken for appendicitis. The confirmed opium-eater usually has a sallow, pasty
complexion, is emaciated, and becomes prematurely gray. He is restless, irrita-
ble, and unable to remain quiet for any time. Itching is a common symptom.
The sleep is disturbed, the appetite and digestion are deranged, and except
when directly under the influence of the drug the mental condition is one of
depression. Occasionally there are profuse sweats, which may be preceded by
chills. The pupils, except when under the direct influence of the drug, are
dilated, sometimes unequal. In one case there was a persistent oedema of the
legs without sufficient renal changes or anasmia to account for it. Persons
addicted to morphia are inveterate liars, and no reliance whatever can be
placed upon their statements. In many instances this is not confined to mat-
ters relating to the vice. In women the symptoms may be associated with
those of pronounced hysteria or neurasthenia. The practice may be contin-
ued for an indefinite time, usually requiring increase in the dose until ulti-
mately enormous quantities may be needed to obtain the desired effect.
Finally a condition of asthenia is induced, in which the victim takes little or
no food and dies from the extreme bodily debility. An increase in the dose
is not always necessary, and there are habitues who reach the point of satis-
faction with a daily amount of 2 or 3 grains of morphia, and who are able
to carry on successfully for many years the ordinary business of life. They
may remain in good physical condition, and indeed often look ruddy.
Treatment.— The treatment of the morphia habit is extremely difficult, and
can rarely be successfully carried out by the general practitioner. Isolation,
systematic feeding, and gradual withdrawal of the drug are the essential ele-
ments. As a rule, the patients must be under control in an institution and
should be in bed for the first ten days. It is best in a majority of cases to
reduce the morphia gradually. The diet should consist of beef-juice, milk, and
egg-white, which should be given at short intervals. The sufferings of the pa-
tients are usually very great, more particularly the abdominal pains, sometimes
nausea and vomiting, and the distressing restlessness. Usually within a week or
ten days the opium may be entirely withdrawn. In all eases the pulse should be
carefully watched and, if feeble, stimulants should be given, with the aromatic
spirits of ammonia and digitalis. For the extreme restlessness a hot bath is
serviceable. The sleeplessness is the most distressing symptom, and various
drugs may have to be resorted to, particularly hyoscine and sulphonal and
sometimes, if the insomnia persist, morphia itself.
It is essential in the treatment of a case to be certain that the patient has
LEAD-POISONING. 375
no means of obtaining morphia. Even under the favorable circumstances of
seclusion in an institution, and constant watching by a night and a day nurse,
I have known a patient to practice deception for a period of three months.
After an apparent cure the patients are only too apt to lapse into the habit.
The condition is one which has become so common, and is so much on
the increase, that physicians should exercise the utmost caution in prescrib-
ing morphia, particularly to female patients. Under no circumstances should
a patient with neuralgia or sciatica be allowed to use the hypodermic syringe,
and it is even safer not to intrust this dangerous instrument to the hands of
the nurse.
III. LEAD-POISONING (Plumbism; Saturnism).
Etiology. — The disease is wide-spread, particularly in lead-workers and
among plumbers, painters, and glaziers. The metal is introduced into the
system in many forms. Miners usually escape, but those engaged in the smelt-
ing of lead-ores are often attacked. Animals in the neighborhood of smelt-
ing furnaces have suffered with the disease, and even the birds that feed on
the berries in the neighborhood may be affected. Men engaged in the white-
lead factories are particularly prone to plumbism. Accidental poisoning may
come in many ways; most commonly by drinking water which has passed
through lead pipes or been stored in lead-lined cisterns. Wines and cider
which contain acids quickly become contaminated in contact with lead. It
was the frequency of colic in certain of the cider districts of Devonshire which
gave the name of Devonshire colic, as the frequency of it in Poitou gave the
name colica Pictonum. Among the innumerable sources of accidental poi-
soning may be mentioned milk, various sorts of beverages, hair dyes, false
teeth, and thread. We have had in the Johns Hopkins Hospital four cases
following the use of lead and opium pills for dysentery, of which cause Miller
(Therapeutic Gazette, 1904) has collected many cases from the literature. It
has also followed the use of Emplastrum Diachylon to produee abortion, and
there is a case reported in an infant from the application of lead-water on
the mother's nipples. One grain every three hours for three days, and two
grains every three hours for one day, have caused signs of poisoning. A seri-
ous outbreak of lead-poisoning, which was investigated by David D. Stewart,
occurred in Philadelphia, owing to the disgraceful adulteration of a baking-
powder with chromate of lead, which was used to give a yellow tint to the
cakes. Lead given medicinally rarely produces poisoning.
All ages are attacked, but J. J. Putnam states that children are relatively
less liable. The largest number of cases occur between thirty and forty. Ac-
cording to Oliver, females are more susceptible than males. He states that
they are much more quickly brought under its influence, and in a recent epi-
demic in which a thousand cases were involved the proportion of females to
males was four to one.
The lead gains entrance to the system through the lungs, the digestive
organs, or the skin. Poisoning may follow the use of cosmetics containing
lead. Through the lungs it is freely absorbed. The chief channel, according
to Oliver, is the digestive system. It is rapidly eliminated by the kidneys and
skin, and is present in the urine of lead-workers. The susceptibility is re-
376 THE INTOXICATIONS AND SUN-STROKE.
markably varied. The s}Tnptoms may be manifest within a month of expo-
sure. On the other hand, Tanquerel (des Planches) met with a case in a
man who had been a lead-worker for fifty-two years.
Morbid Anatomy. — Small quantities of lead occur in the body in health.
J. J. Putnam's reports show that of 150 persons not presenting symptoms of
lead-poisoning traces of lead occurred in the urine of 35 per cent.
In chronic poisoning lead is found in the various organs. The affected
muscles are yellow, fatt}^, and fibroid. The nerves present the features of
a peripheral degenerative neuritis. The cord and the nerve-roots are, as a
rule, uninvolved. In the primary atrophic form the ganglion cells of the
anterior horns are probably implicated. In the acute fatal cases there may
be the most intense entero-colitis.
Clinical Forms. — iVcuTE Poisoning. — We do not refer here to the acci-
dental or suicidal cases, which present vomiting, pain in the abdomen, and
collapse symptoms. In workers in lead there are several manifestations which
follow a short time after exposure and set in acutely. There may be, in the
first place, a rapidly developing anaemia. Acute neuritis has been described,
and convulsions, epilepsy, and a delirium, which may be, as Stephen Mac-
kenzie has noted, not unlike that produced by alcohol. There are also cases
in which the gastro-intestinal symptoms are most intense and rapidly prove
fatal. There was admitted under my care in the Philadelphia Hospital a
painter, aged fifty, suffering with anaemia and severe abdominal pain, which
had lasted about a week. He had vomiting, constipation at first, afterward
severe diarrhcea and melasna, with distention and tenderness of the abdo-
men. There were albumin and tube-casts in the urine. The temperature was
usually subnormal. Death occurred at the end of the second week. There
was found the most intense entero-colitis with hemorrhages and exudation.
These acute forms occur more frequently in persons recently exposed, and,
according to Mackenzie, are more frequent in winter than in summer. Da
Costa has reported the onset of hemiplegia after three days' exposure to the
poison.
Chronic Poisoning.
(a) Blood Changes. — A moderate grade of ancemia, the so-called saturnine
cachexia, is usually present. The corpuscles do not often fall below 50 per
cent. Many of the red cells show a remarkable granular, basophilic degenera-
tion when stained with Jenner's stain, or with polychrome methylene blue.
Grawitz first demonstrated their presence in cases of pernicious ansemia, and
Pepper (tertius) and White showed that they were constantly present in lead-
poisoning. Further observations by Vaughan and others have shown that
such granulations are found in the blood in a great variety of conditions, even
in normal blood, but that they are most numerous in lead-poisoning, in which
their occurrence in very large numbers is of considerable value in diagnosis.
Cadwalader has shown the constant presence of nucleated red Mood-corpuscles
even when the anaemia is of very slight grade.
(h) Blue line on the gums, which is a valuable indication, but not in-
variably present. Two lines must be distinguished: one, at' the margin
between the gums and teeth, is on, not in the gums, and is readily removed
by rinsing the mouth and cleansing the teeth. The other is the well-known
characteristic blue-black line at the margin of the gum. The color is not
LEAD-POISONING. 377
uniform, but being in the papillae of the gums the line is, as seen with a
magnifying-glass, interrupted. The lead is absorbed and converted in the
tissues into a black sulphide by the action of sulphuretted hydrogen from the
tartar of the teeth. The line may form in a few days after exposure (Oliver)
and disappear within a few weeks, or may persist for many months. Philip-
son has noted the occurrence of a black line in miners, due to the deposition
of carbon.
The most important symptoms of chronic lead-poisoning are colic, lead-
palsy, and the encephalopathy. Of these, the colic is the most frequent. Of
Tanquerel's cases, there were 1,217 of colic, 101 of paralysis, and 72 of enceph-
alopathy.
(c) Colic is the most common symptom of chronic lead-poisoning. It
is often preceded by gastric or intestinal symptoms, particularly constipation.
The pain is over the whole abdomen. The colic is usually paroxysmal, like
true colic, and is relieved by pressoire. There is often, in addition, between
the paroxysms a dull, heavy pain. There may be vomiting. During the
attack, as Riegel noted, the pulse is increased in tension and the heart's action
is retarded. Attacks of pain with acute diarrhoea may recur for weeks or
even for three or four years.
Certain of the cases with acute colic may present the features of an acute
intra-abdominal inflammatory condition. A case was lately admitted to the
surgical wards with a diagnosis of appendicitis. Localized pain, slight fever,
and moderate leucocytosis may be present. The cases may simulate intestinal
obstruction. The history, the presence of a blue line on the gums, and the
blood changes are of importance in differential diagnosis.
(d) Lead-palsy. — This is rarely a primary manifestation. Among 54
cases of lead-poisoning treated in the J. H. H. and dispensary, there were
30 cases of lead-paralysis (H. M. Thomas). The upper limbs are most fre-
quently affected. In 26 cases the arms alone were affected, and 18 of these
showed the typical double wrist-drop. In 7 the right arm alone was involved,
and in one the left. In 4 cases both arms and legs were attacked. The onset
may be acute, subacute, or chronic. It usually occurs without fever. In its
distribution it may be partial, limited to a muscle or to certain muscle groups,
or generalized, involving in a short time the muscles of the extremities and
the trunk. Madame Dejerine-Klumpke recognizes the following localized
forms :
(1) Antebrachial type, paralysis of the extensors of the fingers and of
the wrist. In this the musculo-spiral nerve is involved, causing the char-
acteristic wrist-drop. The supinator longus usually escapes. In the long-
continued flexion of the carpus there may be slight displacement backward
of the bones, with distention of the synovial sheaths, so that there is a promi-
nent swelling over the wrist. This, which is sometimes known as Gruebler's
tumor, though not of any moment, is often very annoying to the patient.
(2) Brachial type, which involves the deltoid, the biceps, the brachialis
anticus, and the supinator longus, rarely the pectorals. The atrophy is of the
scapulo-humeral form. It is bilateral, and sometimes follows the first form,
but it may be primary.
(3) The Aran-Duchenne type, in which the small muscles of the hand
and of the thenar and hypothenar eminences are involved; so that we have a
378 THE INTOXICATIONS AND SUN-STROKE.
paralysis closely resembling that of the early stage of polio-myelitis anterior
chronica. The atrophy is marked, and may be the first manifestation of the
lead-palsy. Mobius has shown that this form is particularly marked in tailors.
(4) The peroneal type. According to Tanquerel, the lower limbs are
involved in the proportion of 13 to 100 of the upper limbs. The lateral
peroneal muscles, the extensor communis of the toes, and the extensor proprius
of the big toe are involved, producing the steppage gait.
(5) Laryngeal form. Adductor paralysis has been noted by Morell Mac-
kenzie and others in lead-palsy.
Generalized Palsies. — There may be a slow, chronic paralysis, gradually
involving the extremities, beginning with the classical picture of wrist-drop.
More frequently there is a rapid generalization, producing complete paralysis
in all the muscles of the parts in a few days. It may pursue a course like
an ascending paralysis, associated with rapid wasting of all four limbs. Such
cases, however, are very rare. Death has occurred by involvement of the dia-
phragm. Oliver reports a case of Philipson's in which complete paralysis
supervened. A case of generalized paralysis was admitted last winter (1904)
in which the paralysis began in the legs after but two weeks' work as an
enameler. It spread rapidly, so that in a little over a week he was bed-
ridden, and on admission to the hospital nearly every muscle below the neck
was involved. The diaphragm was completely paralyzed. He was walking
about when he left the hospital, though there was still some weakness remain-
ing. Dejerine-Klumpke also recognizes a febrile form of general paralysis
in lead-poisoning, which may closely resemble the subacute spinal paralysis
of Duchenne.
There is also a primary saturnine muscular atrophy in which the weak-
ness and wasting come on together. It is this form, according to Gowers,
which most frequently assumes the Aran-Duchenne type.
The electrical reactions are those of lesions of the lower motor segment,
and will be described under diseases of the nerves." The degenerative reac-
tion in its different grades may be present, depending upon the severity of
the disease.
Usually with the onset of the paralysis there are pains in the legs and
joints, the so-called saturnine arthralgias. Sensation may, however, be
unaffected.
(e) The cerebral symptoms are numerous.. Seven of our cases showed
marked cerebral involvement. One of the cases had delusions and maniacal
excitement and had to be removed to an insane hospital. In other cases there
occurred transient delirium, attacks of unconsciousness, and in one case con-
vulsions. Optic neuritis or neuro-retinitis may occur. Hysterical symptoms
occasionally occur in girls. Convulsions are not uncommon, and in an adult
the possibility of lead-poisoning should always be considered. True epilepsy
may follow the convulsions. An acute delirium may occur with hallucina-
tions. The patients may have trance-like attacks, which follow or alternate
with convulsions. A few cases of lead encephalopathy finally drift into
lunatic asylums. Tremor is one of the commonest manifestations of lead-
poisoning.
(/) Arteriosclerosis. — Lead-workers are notoriously subject to arterio-
sclerosis with contracted kidneys and hypertrophy of the heart. The cases
ARSENICAL POISONING. 379
usually show distinct gouty deposits, particularly in the big-toe joint; but
in this country acute gout in lead-workers is rare. According to Sir Wil-
liam Eoberts, the lead favors the precipitation of the crystalline urates of
the tissues. Ealfe has shown that lead diminishes the alkalinity of the
blood, and so lessens the solubility of the uric acid.
Prognosis. — In the minor manifestations this is good. According to Gow-
ers, the outlook is bad in the primary atrophic form of paralysis. Convulsions
are, as a rule, serious, and the mental symptoms which succeed may be perma-
nent. Occasionally the wrist-drop persists.
Treatment. — Prophylactic measures should be taken at all lead-works, but,
unless employes are careful, poisoning is apt to occur even under the most
favorable conditions. Cleanliness of the hands and of the finger-nails, fre-
quent bathing, and the use of respirators when necessary, should be insisted
upon. When the lead is in the system, the iodide of potassium should be
given in from 5- to 10-grain doses three times a day. For the colic, local
applications and, if severe, morphia may be used. An occasional morning
purge of magnesium sulphate may be given. For the ansemia iron should
be used. In the very acute cases it is well not to give the iodide, as, accord-
ing to some writers^ the liberation of the lead which has been deposited in the
tissues may increase the severity of the symptoms. For the local palsies mas-
sage and the constant current should be used.
IV. ARSENICAL POISONING.
Acute poisoning by arsenic is common, particularly by Paris green and
such mixtures as " Eough on Eats," which are used to destroy vermin and
insects. The chief symptoms are intense pain in the stomach, vomiting, and,
later, colic, with diarrhoea and tenesmus ; occasionally the symptoms are those
of collapse. If recovery takes place, paralysis may follow. The treatment
should be similar to that of other irritant poisons — rapid removal with the
stomach pump, the promotion of vomiting, and the use of milk and eggs.
If the poison has been taken in solution, dialyzed iron may be used in doses
of from 6 to 8 drachms.
Chronic Arsenical Poisoning. — Arsenic is used extensively in the arts,
particularly in the manufacture of colored papers, artificial fiowers, and in
many of the fabrics employed as clothing. The glazed green and red papers
used in kindergartens also contain arsenic. It is present, too, in many wall-
papers and carpets. Much attention has been paid to this question of late
years, as instances of poisoning have been thought to depend upon wall-papers
and other household fabrics. The arsenic compounds may be either in the
form of solid particles detached from the paper or as gaseous volatile bodies
formed from arsenical organic matter by the action of several moulds, notably
Penicilium trevicaule, Mucor niucedo^ etc. (Gosio). In moisture, and at a
temperature of from 60° to 95° F., a volatile compound is set free, probably
"an organic derivative of arsenic pentoxide " (Sanger). The chronic poi-
soning from fabrics and wall-papers may be due, according to this author,
to the ingestion of minute continued doses of this derivative. Contaminated
glucose, used in manufacturing beer, caused the recent epidemic of poison-
ing at Manchester. The associated presence' of selenium compounds may have
380 THE INTOXICATIONS AND SUN-STROKE.
plaj'ed a part in the production of the poisoning (TunnielifEe and Rosenheim).
Arsenic is eliminated in all the secretions, and has been found in the milk.
J. J. Putnam, it should be remembered, has shown that it is not uncommon
to find traces of arsenic in the urine of many persons in apparent health (30
per cent). The effects of moderate quantities of arsenic are not infrequently
seen in medical practice. In chorea and in pernicious anaemia, steadily in-
creasing doses are often given until the patient takes from 15 to 20 drops of
FoTvler s solution three times a day. Flushing and In-perEemia of the skin,
puffiness of the eyelids or above the eyebrows, nausea, vomiting, and diarrhoea
are the most common symptoms. Eedness and sometimes bleeding of the
gums and salivation occur. In the protracted administration of arsenic
patients may complain of numbness and tingling in the fingers. Cutaneous
pigmentation and keratosis are very characteristic, and as a late rare sequence
of the latter, epithelioma. In chorea neuritis has occurred, and a patient of
mine with Hodgkin's disease had multiple neuritis after taking ^iv oj of Fow-
ler's solution in seventy-five days, during which time there were fourteen days
on which the drug was omitted.
In the Manchester epidemic nearly all cases presented signs of neuritis
and lesions of the skin. In some the sensory disturbances predominated,
in others the motor, the individuals being unable to walk or to use their
hands. In a certain number there was muscular inco-ordination, resembling
that of locomotor ataxia. Eapid muscular atrophy characterized some cases.
In not a few patients a condition of erythromelalgia was present. Occasion-
ally a catarrh of the respiratory and alimentary tracts was the chief feature.
Pigmentation, keratosis, and herpes were the most characteristic cutaneous
manifestations (Kehmack and Kirkby, Arsenical Poisoning in Beer Drink-
ers). How far similar symptoms are to be attributed to the small quantities
of arsenic absorbed from wall-papers and fabrics is by some considered doubt-
ful. That children and adults may take with impunity large doses for months
without unpleasant effects, and the fact of the gradual establishment of a
toleration which enables Styrian peasants to take as much as 8 grains of arse-
nious acid in a day, speak strongly against it. On the other hand, as Sanger
states, we do not know accurately the effects of many of the compounds in
minute and long-continued doses, notably the arsenates.
Arsenical paralysis has the same characteristics as lead-palsy, but the legs
are more affected than the arms, particularly the extensors and peroneal
group, so that the patient has the characteristic steppage gait of peripheral
neuritis.
The electrical reaction in the muscles may be disturbed before there is
any loss of power, and when the patient is asked to extend the wrist fully and
to spread the fingers slight weakness may be detected early.
V. FOOD POISONING.
There may be " death in the pot "' from many causes. Food poisons may
be endogenous or exogenous. Those articles in which the poison is of endoge-
nous origin can scarcely be designated as foods. The poisonous mushroom,
for example, is often mistaken for the edible form. The former is injurious
because it normally produces a highly poisonous alkaloid, muscarine. Cer-
FOOD POISONING. 381
tain fish also produce normal physiological but toxic products. When eaten
by mistake, as frequently occurs in the West Indies and Japan, these fish may
cause poisonous symptoms. The exogenous origin of food poisons is by far
the commonest. Under this head come those foods which are rendered poison-
ous by accidental contamination from outside sources. Food may contain
the specific organisms of disease, as of tuberculosis or trichinosis; milk and
other foods may become infected with typhoid bacilli, and so convey the disease.
Animals (or insects, as bees) may feed on substances which cause their
flesh or products to be poisonous to man.
The grains used as food may be infected with fungi and cause the epi-
demics of ergotism, etc.
Foods of all sorts may become contaminated with the bacteria of putre-
faction, the products of which may be highly poisonous.
The term " ptomaine poisoning " has been popularized to such an extent
that it is used synonymously with food poisoning. The term ptomaine was
introduced twenty-five years ago by the Italian chemist, Selmi, to designate
basic alkaloidal products formed in putrefaction. It is largely through the
labors of Brieger that our knowledge of ptomaines was gained. Mytilotoxin,
found in poisonous mussels, is of this class, and is by far the most poisonous
of the known ptomaines.
Among the more common forms are the following:
(1) Meat Poisoning. — Cases have usually followed the eating of sausages
or pork-pie or head-cheese, and also occasionally beef, veal, never mutton.
Sausage poisoning, which is known by the name of botulism or allantiasis, has
long been recognized, and there have been numerous outbreaks, particularly
in parts of Germany. Similar attacks have been produced by ham and by
head-cheese. The precise nature of the kreotoxicons has not yet been deter-
mined. Other outbreaks have followed the eating of beef and veal. In the
majority of these cases the meat has undergone decomposition, though the
change may not have been evident to the taste. The organisms which pro-
duce the toxins causing the poisonous symptoms are nearly always anaerobes.
Van Ermengena isolated an organism, to which he gave the name B. botu-
linus, from a diseased ham, which poisoned thirty-four persons, all members
of a musical society, at Ellezelles, in Germany. An organism frequently
found in infected meat is B. enteritidis, first isolated by Gartner in 1888 from
meat which had poisoned a large number of persons. In recent years a num-
ber of epidemics of food poisoning have been shown to be in all probability
caused by the Proteus vulgaris or its related species. Such epidemics have
been reported by Levy and Vesenberg. The symptoms of meat poisoning are
those of acute gastro-intestinal irritation. Ballard's description of the Well-
beck cases, quoted by Vaughan, holds good for a majority of them:
" A period of incubation preceded the illness. In 51 cases where this
could be accurately determined, it was twelve hours or less in 5 cases ; between
twelve and thirty-six hours in 34 cases; between thirty-six and forty-eight
hours in 8 cases; and later than this in only 4 cases. In many cases the
first definite symptoms occurred suddenly, and evidently unexpectedly, but
in some cases there were observed during the incubation more or less feeling
of languor and ill-health, loss of appetite, nausea, or fugitive, griping pains in
the belly. In about a third of the cases the first definite symptom was a sense
382 THE INTOXICATIONS AND SUN-STROKE.
of chilliness, usually with rigors, or trembling, in one case accompanied by
dj^spnoea; in a few cases it was giddiness with faintness, sometimes accom-
panied by a cold sweat and tottering; in others the first symptom was head-
ache or pain somewhere in the trunk of the body — e. g., in the chest, back,
between the shoulders, or in the abdomen, to which part the pain, wherever
it might have commenced, subsequently extended. In one case the first symp-
tom noticed was a difficulty in swallowing. In tAvo cases it was intense thirst.
But however the attack may have commenced, it was usually not long before
pain in the abdomen, diarrhoea, and vomiting came on, diarrhoea being of
more certain occurrence than vomiting. The pain in several cases commenced
in the chest or between the shoulders, and extended first to the upper and
then to the lower part of the abdomen. It was usually very severe indeed,
quickly producing prostration or faintness, with cold sweats. It was variously
described as crampy, burning, tearing, etc. The diarrhoeal discharges were
in some cases quite unrestrainable, and (where a description of them could
be obtained) were said to have been exceedingly offensive and usually of a
dark color. Muscular weakness was an early and very remarkable symptom
in nearly all the cases, and in many it was so great that the patient could only
stand by holding on to something. Headache, sometimes severe, was a com-
mon and early symptom; and in most cases there was thirst, often intense
and most distressing. The tongue, -when observed, was described usually as
thickly coated with a brown, velvety fur, but red at the tip and edges. In
the early stage the skin was often cold to the touch, but afterward fever set
in, the temperature rising in some cases to 101°, 103°, and 104° F. In a
few severe cases, where the skin was actually cold, the patient complained of
heat, insisted on throwing off the bedclothes, and was very restless. The
pulse in the height of the illness became quick, counting in some cases
100 to 128."
Many instances are on record of poisoning by canned goods, particu-
larly meat. Some of these, according to John G. Johnson, have been cases
of corrosive poisoning from muriate of zinc and muriate of tin used as an
amalgam, but poisonous effects identical with those just described have fol-
lowed the use of canned meats.
Certain game birds, particularly the grouse, are stated to be poisonous,
in special districts and at certain seasons of the year. It is a noteworthy fact
that mutton and lamb have thus far not been implicated as a cause of food
poisoning.
(3) Poisoning by Milk Products. — (a) The poisonous effects which fol-
low the drinking of milk infected with saprophytic bacteria, is considered in
the section on the diarrhoea of infants.
(b) Cheese Poisoning. — Various milk products, ice cream, custard, and
cheese may prove highly poisonous. Among the poisons Vaughan now states
that the tyrotoxicon " is not the one most frequently present, nor is it the
most active one." In one epidemic he and ISTovy have isolated from cheese a
substance belonging to the poisonous albumins, and in an extensive ice-cream
epidemic Vaughan and Perkins found in the ice cream a highly pathogenic
bacillus, but its toxin has not been separated.
The symptoms are those of acute gastro-intestinal irritation, and are
similar to those already detailed by Ballard.
FOOD POISONING. 383
(3) Poisoning by Shell-fish and Fish. — (a) Mussel Poisoning. — Brieger
has separated a ptomaine — mytilotoxin — which exists chiefly in the liver of
the mussel. The observations of Schmidtmann and Cameron have shown
that the mussel from the open sea only becomes poisonous when placed in filthy
waters, as at Wilhelmshafen.
Dangerous, even fatal, effects may follow the eating of either raw or cooked
mussels. The symptoms are those of an acute poisoning with profound action
on the nervous system, and without gastro-intestinal manifestations. There
are numbness and coldness, no fever, dilated pupils, and rapid pulse; death
occurs sometimes within two hours with collapse symptoms. In an epidemic
at Wilhelmshafen, Germany, in 1885, nineteen persons were attacked, four
of whom died. Salkowski and Brieger isolated the mytilotoxin from
specimens of the mussels. Poisoning occasionally follows the eating of
oysters which are stale or decomposed. The symptoms are usually gastro-
intestinal.
(b) Fish Poisoning. — There are two distinct varieties; in one the poison
is a physiological product of certain glands of the fish, in the other it is a
product of bacterial growth. The salted sturgeon used in parts of Russia
has sometimes proved fatal to large numbers of persons. In the middle parts
of Europe the barb is stated to be sometimes poisonous, producing the so-
called " harben cholera." In China and Japan various species of the tetrodon
are also toxic, sometimes causing death within an hour, with, symptoms of
intense disturbance of the nervous system. Beri-beri is thought by some to
be due to the consumption of certain kinds of fish.
(4) Grain and Vegetable Food Poisoning.
(1) Ergotis7n. — The prolonged use of meal made from grains contami-
nated with the ergot fungus (claviceps purpurea) causes a series of symp-
toms know as ergotism, epidemics of which have prevailed in different parts
of Europe. Two forms of this chronic ergotism are described — tbe one,
gangrenous, is believed to be due to the sphacelinic acid, the other, convulsive,
or spasmodic, is due to the cornutin. In the former, mortification affects
the extremities — usually the toes and fingers, less commonly the ears and
nose. Preceding the onset of the gangrene there are usually anesthesia,
tingling, pains, spasmodic movements of the muscles, and gradual blood stasis
in certain vascular territories.
The nervous manifestations are very remarkable. After a prodromal stage
of ten to fourteen days, in which the patient complains of weakness, headache,
and tingling sensations in different parts of the body, perhaps accompanied
with slight fever, symptoms of spasm develop, producing cramps in the mus-
cles and contractures. The arms are flexed and the legs and toes extended.
These spasms may last from a few hours to many days and relapses are fre-
quent. In severer cases epilepsy develops and the patient may die in convul-
sions. Mental symptoms are common, manifested sometimes in a prelimi-
nary delirium, but more commonly, in the chronic poisoning, as melancholia
or dementia. Posterior spinal sclerosis occurs in chronic ergotism. In the
interesting group of 29 cases studied by Tuczek and Siemens, 9 died at various
periods after the infection, and four post mortems showed degeneration of the
posterior columns. A condition similar to tabes dorsalis is gradually pro-
duced by this slow degeneration in the spinal cord.
384 THE INTOXICATIONS AND SUN-STROKE.
(2) Lathyrism (Lupinosis). — An affection produced by the use of meal
from varieties of vetches, chiefly the Lathyrus sativus and L. cicera. The
grain is popularly known as the chick-pea. The grains are usually powdered
and mixed with the meal from other cereals in the preparation of bread. As
early as the seventeenth century it was noticed that the use of flour with which
the seeds of the Lathyrus were mixed caused stiffness of the legs. The subject
did not, however, attract much attention before the studies of James Irving,
in India, who between 1859 and 1868 jiublished several important communi-
cations, describing a form of spastic parajjlegia affecting large numbers of
the inhabitants in certain regions of India and due to the use of meal made
from the Lathyrus seeds. It also produces a spastic paraplegia in animals.
The Italian observers describe a similar form of paraplegia, and it has been
observed in Algiers by the French physicians. The condition is that of a
spastic paralysis, involving chiefly the legs, which may proceed to complete
paraplegia. The arms are rarely, if ever, affected. It is evidently a slow
sclerosis induced under the influence of this toxic agent. The precise ana-
tomical condition, so far as I can ascertain, has not yet been determined.
(3) Pellagra. — Maidismus, a disease due to the use of altered maize, occurs
extensively in parts of Italy, in the south of France, and in Spain. Searcy,
Babcock, Wood, and Bellamy have shown (1907-1908) that it is not an un-
common disease in the southern parts of the United States; many of the
cases are acute. A case has been described in England (1906). In the
early stage the symptoms are indefinite, characterized by debility, pains in
the sj^ine, insomnia, digestive disturbances, more rarely diarrhoea. The first
clear manifestation of the disease is the pellagral erythema, which almost
invariably appears in the spring. This is followed by desiccation and exfolia-
tion of the epidermis, which becomes very rough and dry, and occasionally
crusts form, beneath which there is suppuration. With these cutaneous mani-
festations there are digestive troubles — salivation, dyspepsia, and diarrhoea —
which may be of a dysenteric nature. After lasting for a few months improve-
ment occurs in the milder cases and convalescence is gradvially established.
In the more severe and chronic forms there are pronounced nervous symptoms
— headache, backache, spasms, and finally paralysis and mental disturbance.
The paralytic condition affects the legs and leads gradually to paraplegia. The
mental manifestations, which are rarely met with until the third or fourth
attack, are melancholia or suicidal mania. Finally, there may be a condition
of the most pronounced cachexia. Symmetrical gangrene sometimes occurs.
The anatomical findings are indefinite. Chronic degenerative changes
have been found, particularly fatty degeneration and a peculiar pigmentation
in the viscera. The measures to be employed are change in diet, removal from
the infected district, and, as a prophylaxis, proper ripening and preservation
of the corn, the toxic changes in which are apparently due to the action of a
special organism.
(4) Potato-poisoning. — It has long been known that potatoes contain
normally a very small amoimt (about 0.06 per cent) of the poisonous prin-
ciple, solanin, but it is only quite recently that it has been discovered that,
under certain circumstances, they may contain the poison in amounts sufficient
to cause grave disturbance of the system. The increase is due to the action
of at least two species of bacteria, Bacterium solaniferum non-colorabile and
SUN-STROKE. 385
Bacterium solaniferum colorahile, and occurs in those tubers which, during
growth, have lain partially exposed above ground, and in those which, during
storage, have become well sprouted. ' The most extensive outbreak of potato-
poisoning recorded occurred in 1899 in a German regiment, fifty-six members
of which, after eating sprouted potatoes, were seized with chills, fever, head-
ache, vomiting, diarrhoea, colic, and great prostration. Many were jaundiced
and several collapsed, but all recovered. Samples of the remaining potatoes
yielded 0.38 per cent of solanin, and this would indicate that a full portion
must have contained about 5 grains.
Treatment. — The source of the infection must be ascertained and the
ofi^ending food destroyed. The stomach should be washed out and the bowels
evacuated by a brisk saline purge. Little can be done for the symptoms of
poisoning of the nervous system. Saline infusions, hypodermically, may be
of service in promoting the elimination of the toxins.
VI. SUN-STROKE (Siriasis).
{Heat Exhaustion ; Insolation; Thermic Fever; Heat-stroke; Coup de Soleil.)
Definition. — A condition produced by exposure to excessive heat.
It is one of the oldest of recognized diseases ; two instances are mentioned
in the Bible. It was long confounded with apoplexy. The Anglo-Indian
surgeons gave admirable descriptions of it. In the United States the most
important contributions have come from the New York Hospital and the
Pennsylvania Hospital; from the former, the studies of Swift and Darrach,
from the latter, the papers of Gerhard, George B. Wood, the elder Pepper, and
Levick. In Kew Orleans, Bennett Dowler studied the disease and recognized
the difference between heat exhaustion and sun-stroke. Two forms are recog-
nized, heat exhaustion and heat-stroke.
Heat Exhaustion. — Prolonged exposure to high temperatures, particu-
larly when combined with physical exertion, is liable to be followed by extreme
prostration, collapse, restlessness, and in severe cases by delirium. The sur-
face is usually cool, the pulse small and rapid, and the temperature may be
subnormal — as low as 95° or 96°. The individual need not necessarily be
exposed to the direct rays of the sun, but the condition may come on at night
or when working in close, confined rooms. It may also follow exposure to
great artificial heat, as in the engine rooms of the Atlantic steamships.
Sun-stroke or Thermic Fever, — The cases are chiefly found in persons who,
while working very hard, are exposed to the sun. Soldiers on the march
with their heavy accoutrements are particularly liable to attack. In the
larger cities of this country the cases are almost exclusively confined to work-
men who are much exposed and, at the same time, have been drinking beer
and whisky.
Morbid Anatomy and Pathology. — Bigor mortis occurs early. Putrefac-
tive changes may come on with great rapidity. The venous engorgement is
extreme, particularly in the cerebrum. The left ventricle is contracted
(Wood), and the right chamber dilated. The blood is usually fluid; the
lungs are intensely congested. Parenchymatous changes occur in the liver
and kidneys. ' •
26
386 THE INTOXICATIONS AND SUN-STROKE.
According to Wood, " lieat exhaustion with lowered temiDerature repre-
sents a sudden vaso-motor palsy, i. e., a condition in which the existing effect
of the heat j)aral3'zes the centre in the medulla."' On the other hand, thermic
fever is held to be due to paralysis under the influence of the extreme external
heat of the centre in the medulla which regulates the disposition of the bodily
heat. Owing to this disturbance, more heat is produced and less given ofE
than normally.
Sambron has (B. M. J., 1898, i) advanced the view that siriasis is an
infectious disease. He argues that heat alone can not cause it, that it occurs
in certain localities and in epidemic outbursts, and persons acclimatized have
a relative immunity, etc.
Symptoms. — The patient may be struck down and die within an hour
with sjTiiptoms of heart-failure, dyspncea, and coma. This form, sometimes
known as the asphyxial, occurs chiefly in soldiers and is graphically described
by Parkes. Death indeed may be almost instantaneous, the victims falling
as if struck upon the head. The more usual form comes on during exposure,
with pain in the head, dizziness, a feeling of oppression, and sometimes nausea
and vomiting. Visual disturbances are common, and a patient may have col-
ored vision. Diarrhoea or frequent micturition may supervene. Insensi-
bility follows, which may be transient or which deepens into a profound coma.
The patients are usually admitted to hospital in an unconscious state, with
the face flushed, the skin pungent, the pulse rapid and full, and the tempera-
ture ranging from 107° to 110°, or even higher, as shown in the accompany-
ing chart. F. A. Packard states that of the 31 cases admitted to the Penn-
sylvania Hospital in the summer of 1887, in a majority of them the tempera-
ture was between 110° and 111°. In one case the temperature was 112°. The
breathing is labored and deep, sometimes stertorous. Usually there is com-
plete relaxation of the muscles, but twitchings, jactitation, or very rarely con-
vulsions may occur. The pupils may at first be dilated, but by the time the
cases are admitted to hospital they are (in a majorit}') extremely contracted.
Petechise may be present upon the skin. In the fatal cases the coma deepens,
the cardiac pulsations become more rapid and feeble, the breathing becomes
hurried and shallow and of the Che}Tie-Stokes type. The fatal termination
may occur within twent3-four or thirty-six hours. Favorable indications are
the return of consciousness and a fall in the fever. The recovery in these
cases may be complete. In other instances there are remarkable after-effects,
the most constant of which is a permanent inability to bear high temperatures.
Such patients become very uneasy when the thermometer reaches 80° F. in
the shade. Loss of the power of mental concentration and failure of memory
are more constant and very troublesome sequelae. Such patients are always
worse in the hot weather. Occasionally there are convulsions, followed by
marked mental disturbance. Dercum has described peripheral neuritis as
a sequence, and the patient whose chart is here given had an acute neu-
ritis in the legs. This is a point in favor of the infectious nature of the
disease.
Guiteras has called attention to a form of fever occurring in the South,
known in Florida as " Florida fever," in the Carolinas as " country fever,"
and in tropical countries as fievre inflammatoire. The cases last for a vari-
able time, and are mistaken for malaria or t^'phoid; but he believes them
SUN-STROKE.
387
to be entirely distinct and due to a prolonged action of the high tempera-
tures. He has called the condition a " continued thermic fever."
The diagnosis of heat exhaustion from thermic fever is readily made, as
the difference between the two conditions is striking. " In solar exhaustion
the skin is moist, pale, and cool; the breathing is easy though hurried; the
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. (Rectal Temperatures.)
pulse is small and soft; the vital forces fall into a temporary collapse; the
senses remain entire" (Dowler) ; whereas in sun-stroke or heat apoplexy
there is usually unconsciousness and pyrexia.
The mode of onset, together with the circumstances under which it occurs
and the high temperature, permits thermic fever to be readily differentiated
from apoplexy and coma from other conditions.
Treatment. — In heat exhaustion stimulants should be given freely, and
if the temperature is below normal the hot bath should be used. Ammonia
may be given if necessary. In thermic fever the indications are to reduce
the temperature as rapidly as possible. This may be done by packing the
patient in a bath with ice. Rubbing the body with ice was practised at the
New York Hospital by Darrach in 1857, and is an excellent procedure to
lower the temperature rapidly. Ice-water enemata may also be employed.
At the Pennsylvania Hospital in the summer of 1887 the ice-pack was used
with great advantage. Of 31 cases only 13 died, results probably as satis-
factory as can be obtained, considering that many of the patients are almost
388 THE INTOXICATIONS AND SUN-STROKE.
moribund when brought to hospital. They should be compared with Swift's
statistics, in which of 150 cases 78 died. In the cases in which the symptoms
are those of intense asphyxia, and in which death may take place, in a few
minutes, free bleeding should be practised, a procedure which saved Weir
Mitchell when a young man. For the convulsions chloroform should be given
at once. Of other remedies, the antipyretics have been employed, and may be
given when there is any special objection to hydrotherapy, for which, however,
they can not be substituted.
SECTION IV.
OOI^STITUTIO^AL DISEASES.
I. ARTHRITIS DEFORMANS.
Definition. — A chronic disease of the joints of doubtful etiology, charac-
terized by changes in the synovial membranes and peri-articular structures,
and in some cases by atrophic and hypertrophic changes in the bones.
Long believed to be intimately associated with gout and rheumatism
(whence the names rheumatic gout and rheumatoid arthritis), this close rela-
tionship seems now very doubtful, since in a majority of the cases no history
of either affection can be determined. By the studies of the Boston orthopedic
surgeons (Bradford, Goldthwaite, and Lovett) and of Strangeways and his
pupils at Cambridge (England) we are gradually getting a very accurate
knowledge of the anatomical and clinical forms of this common disease.
Etiology. — Age. — A majority of the cases are between the ages of thirty
and fifty. In A. E. Garrod's analysis of 500 cases there were only 25 under
twenty years of age. In my series of 170 cases studied by T. McCrae, in
one half the onset was before the age of thirty years.
Sex. — Among Garrod's 500 cases there were 411 in women. More than
half in my series were in males. In James Stewart's report of 40 cases from
the Eoyal Victoria Hospital only 20 were in females. In women its close asso-
ciation with the menopause has been noted. It seems to be more frequent, too,
in those who have had ovarian or uterine trouble or who are sterile.
Predisposition. — In 216 cases in Garrod's series there was a family history
of joint troubles. About one-third of my series gave a family history of
arthritis. Two or three children in a family may be affected. In America
the incidence in the negro is much less than in the white.
BJieumatism and Gout. — In nearly a third of Garrod's cases there was
a history of gout in the family ; of rheumatism in only 64 cases.
Exposure to cold, wet and damp, errors in diet, worry and care, and local
injuries are all spoken of as possible exciting causes.
At present two chief views prevail as to the etiology of arthritis deformans
— one that it is of nervous origin, the other that it is a chronic infection.
The Eelation of Arthritis Deformans to Diseases op the Nervous
System. — Various forms of arthritis may occur with lesions of the spinal cord,
and it has been held by J. K. Mitchell (Sr.) that changes in the nervous
system are the cause of the joint lesions. This does not seem to be supported
by recent work, which rather supports the view that the disease is the result
of a chronic infection. The rapid muscular atrophy, the associated neuritis,
389
390 CONSTITUTIONAL DISEASES.
the pain, the increase in the reflexes, and the nutritional disturbances suggest
a change in tlie nervous system, but tliis may be secondary to an infective or
toxic process.
Arthritis Deformans as a Chronic Infection. — In recent years this
view has been gaining ground, althougli as 3'et positive bacteriological evidence
is lacking. The infection may be with a specific organism or perhaps with
various ones. Bannatyne, Po}Titon and Pa^me, Chauffard. and others have
obtained organisms from the joints, and suggestive results have followed the
injection of the cultures in animals. But no constant association with any
organism has Ijeen proved. The influence of various infections such as gon-
orrhoea, influenza, etc., is important. Some writers have reported ■ a large
proportion of eases Avith a previous history of gonorrhoea, but this was given
in only 13 per cent of my series.
The acute onset vrith fever, the polyarthritis, the presence of enlarged
glands, and the frequent enlargement of the spleen are all suggestive of an
infection. In a small number cardiac complications occur. The attack may
subside, leaving more or less damage, to recur later with the same features.
And, lastly, a consideration of the form in children described by Still
lends weight to this view, particularly in the wide-spread enlargement of the
lymph-glands and the swelling of the spleen. A number of the very best
students of the disease, as Baumler, of Freiburg, have accepted the infective
theory of origin, which is gaining adherents, though it still lacks demon-
stration.
Morbid Anatomy. — The changes in the joints differ essentially from those
of gout in the absence of deposits of urate of soda, and from chronic rheuma-
tism in the existence of extensive structural alterations, particularly in the
cartilages. We are largely indebted to the magnificent work of Adams for
our knowledge of the anatomy of this disease.
The usual descriptions are of the late stages of the disease when extensive
damage has occurred. There have been few opportunities to study the early
changes, although more frequent operations should extend our knowledge.
The radiographs have aided much in the study of the disease. There are
three main types : ( 1 ) With lesions principally in the sjoiovial membranes
and peri-articular tissues, (3) with atrophic changes in the cartilage and
bones predominating, and (3) with hypertrophy and overgrowth of bone. The
first and second are seen especially in the joints of the extremities, the third
in the spine. Whether these are distinct processes or different manifestations
of the same disease it is difficult to say. The synovial membrane is usually
thickened, and may form large fringes and villi. The peri-articular tissues
show infiltration and swelling. The enlargement is more often due to swelling
about the joint than to bony changes. The cartilage may become soft and
gradually be absorbed or thinned. This seems to begin opposite the point
of greatest involvement of the sjoiovial membrane. The ends of the bones
may become smooth and eburnated, which is usually found in long-standing
cases and in old persons. With this there may be marked atrophy of the
shaft of the bone. Proliferation of bone usually occurs at the margins of
the joints in the form of irregular nodules — the osteophytes. On the knuckles
these are known as Haygarth's nodosities. These may lock the joint. The
formation of bone may also occur in the ligaments, especially in the spine.
ARTHRITIS DEFORMANS. 391
which may be converted into a rigid bony column. Bony anchylosis rarely
occurs in the peripheral joints^, but is common in the spine.
There may be extensive secondary changes. Muscular atrophy is common
and may appear with great rapidity. Subluxation may occur, especially in
the knee and finger joints. The hands often show great deformity, especially
ulnar deflection. Contractures ma}^ follow and the joint become fixed in a
flexed position. Neuritis and trophic disturbances may be associated. The
neuritis is sometimes due to direct extension of the inflammatory process.
Subcutaneous fibroid nodules are occasionally met with.
The radiographs of arthritis deformans are very instructive. The changes
in the bones are very evident. The thinning due to atrophy and the bony
overgrowth can be readily recognized. Erosion of the cartilages is easily seen.
In the type with predominant peri-articular changes the bones show little
alteration.
Symptoms. — For convenience the forms may be described as those with
Heberden's nodes, general progressive arthritis, the mono-articular form, the
vertebral form, and the arthritis deformans of children.
Heberden's Nodes. — In this form the fingers are affected, and "little
hard knobs " develop gradually at the sides of the distal phalanges. They
are much more common in women than in men. They begin usually between
the thirtieth and fortieth year. The subjects may have had digestive troubles
or gout. Heberden, however, says " they have no connection with gout, being
found in persons who never had it." In the early stage the joints may be
swollen, tender, and slightly red, particularly when knocked. The attacks of
pain and swelling may come on in the joints at long intervals or follow
indiscretion in diet. The little tubercles at the sides of the dorsal surface
of the second phalanx increase in size, and give the characteristic appearance
to the affection. The cartilages also become soft, and the ends of the bones
eburnated. Urate of soda is never deposited (Charcot). The condition is
not curable ; but there is this hopeful feature — the subjects of these nodosities
rarely have involvement of the larger joints. They have been regarded, too,
as an indication of longevity. Charcot states that in women with these nodes
cancer seems more frequent.
General Progressive Form. — This occurs in two varieties, acute and
chronic. The acute form may resemble, at its outset, ordinary rheumatic
fever. There is involvement of many joints; swelling, particularly of the
synovial sheaths and bursas; not often redness; but there is moderate fever.
Howard describes this condition as most frequent in j^oung women from twenty
to thirty years of age, often in connection with recent delivery, lactation, or
rapid child-bearing. Acute cases may occur at the menopause. It may also
come on in children. " These patients suffer in their general health, become
weak, pale, depressed in spirits, and lose flesh. In several cases of this form
marked intervals of improvement have occurred; the local disease has ceased
to progress, and tolerable comfort has been experienced perhaps until preg-
nancy, delivery, or lactation again determines a fresh outbreak of the disease "
(Howard).
The chronic form is by far the most common. Most of these have had at
some time an acute attack. The joints are usually involved symmetrically.
The first symptoms are pain on movement and slight swelling, which may be
392 CONSTITUTIONAL DISEASES.
in the joint itself or in the peri-articular sheaths. In some cases the effusion
is marked, in others slight. The local conditions vary greatly, and periods
of improvement alternate with attacks of swelling, redness, and pain. At
first onl}' one or two joints are affected; usually the joints of the hands, then
the knees and feet; gradually other articulations are involved, and in extreme
cases every joint in the body is affected. Pain is an extremely variable sjmip-
tom. Some cases proceed to the most extreme deformity without it ; in others
the suffering is very great, particularly at night and during exacerbations of
the disease. There are cases in which pain of an agonizing character is an
almost constant s}Taptom, requiring for years the use of morpliia.
Gradually the shape of the joints is great!}' altered, partly by the presence
of osteophytes, partly by the great thickening of the capsular ligaments, and
still more by the retraction of the muscles. In moving the affected joint
crepitation can be felt, due to the eburnation of the articular surfaces. TJlti-
matel}^ the joints become completely locked, not by a true bon}^ anchylosis, it
may be by the osteophytes which form around the articular surfaces, like ring-
bone in the horse, but is more often dtte to adhesions and peri-articular thick-
enings. The muscles about the joints undergo important changes. Atrophy
from disuse gradually supervenes, and contractures tend to flex the thigh
upon the abdomen and the leg upon the thigh. There are cases with rapid
muscular wasting, sj'mmetrical involvement of the joints, increased reflexes,
and trophic changes, which strongly suggest a central origin. Xumbness,
tingling, pigmentation or glossiness of the skin, and onychia may be present.
In extreme cases the patient is completely helpless, and lies on one side with
the legs drawn up, the arms fixed, and all the articulations of the extremities
locked. Fortunately, it often happens in these severe general cases that the
joints of the hand are not so much affected, and the patient may be able to
knit or to write, though unable to walk or to use the arms. In many cases,
after involving two or three joints, the disease becomes arrested, and no
further development occurs. It may be limited to the wrists, or to the knees
and wrists, or to the knees and anldes. A majority of the patients finally
reach a quiescent stage, in which they are free from pain and enjoy excellent
health, suffering only from the inconvenience and crippling necessarily asso-
ciated with the disease. Coincident affections are not uncommon. In the
active stage the patients are often ansemic and suffer from dyspepsia, which
may recur at intervals. A small percentage show cardiac lesions. The pulse
rate is frequently higher than normal.
The PARTIAL or moxo-aeticular form affects chiefly old persons, and is
seen particularly in the hip, the knee, the spinal column, or shoulder. It
is, in its anatomical features, identical with the general disease. In the
hip and shoulder the muscles early show wasting, and in the hip the condi-
tion ultimately becomes that already described as morhus coxce senilis. These
cases seem not infrequently to follow an injury. They differ from the
polyarticular form in occurring chiefly in men and at a later period
of life.
The Vertebral Form. — There is a progressive anchylosis of the verte-
bra, causing rigidity of the spine — " poker-back " — spondylitis deformans.
There are two varieties. In one (von Bechterew). in which the disease may
follow trauma or be hereditary, the spine alone is involved, and there are
ARTHRITIS DEFORMANS. 393
pronounced nerve-root symptoms — pain, anesthesia, atrophy of muscles, and
ascending degeneration in the cord; in the other — Striimpell-Marie type —
the hip and shoulder Joints may be involved (spondylose rhizomelique) , and
the nervous symptoms are less prominent. I believe they are both forms of
arthritis deformans, and should neither be regarded nor described as separate
diseases. The cases are more frequent in males than in females; the onset
may be in the upper or in the lower part of the spine. The involvement of
the spine in the lumbar region may cause sciatica. It may be limited to the
neck. There is gradually induced complete immobility, with some kyphosis.
The other joints may not be affected, or the hips and shoulders may be anchy-
losed. The ribs are fixed, the thorax immobile, and the breathing abdominal.
Pressure on the nerve-roots may cause great pain, pargesthesia, and atrophy
of muscles. Von Bechterew thinks that it begins as a meningitis, leads -to
compression of the nerve-roots, loss of function of the spinal muscles, atrophy
of the intervertebral disks, and gradually anchylosis of the spines. Seguin
reported three children in one family with the disease.
Aethkitis Deformans in Children. — Some cases resemble closely the
disease in adults, in others there are very striking differences. A very inter-
esting variety has been differentiated by George F. Still, in which the general
enlargement of the joints is associated with swelling of the l3!mph-glands and
of the spleen. He has studied 22 cases of this character. The following are
among the more striking peculiarities : The onset is almost always before the
second dentition. Girls are more frequently affected than boys. The symp-
toms complained of are usually slight stiffness in one or two joints ; gradually
others become involved. The onset may be more acute with fever, or even
with chills. The enlargement of the joints is due rather to a general thick-
ening of the soft tissues than to a bony enlargement. There is no bony
grating. The limitation of movement may be extreme, owing to the fixation
of the joints, and there may be much muscular wasting. The enlargement
of the lymph-glands is most striking, and may be general; even the supra-
trochlear glands may be as large as hazel-nuts. They increase with the
fever. The edge of the spleen can usually be felt below the costal margin.
Sweating is often profuse and there may be anemia, but heart complica-
tions are rare. The children look puny and generally show arrest of devel-
opment.
Diagnosis. — The early stages may be difficult to diagnose from acute rheu-
matism. The involvement of the smaller joints and the persistence of the
condition in a joint when once attacked are important points. In an advanced
stage it can rarely be mistaken for either rheumatism or gout. Latfe cases
are difficult or impossible to distinguish from chronic rheumatism. It is
important to distinguish from the mono-articular form the local arthritis of
the shoulder-joint which is characterized by pain, thickening of the capsule
and of the ligaments, wasting of the shoulder-girdle muscles, and somfitimes
by neuritis. This is an affection which is quite distinct from arthritis de-
formans, and is, moreover, in a majority of cases curable.
Treatment. — Once established, the disease is rarely curable. After attack-
ing two or three joints it may be arrested. Too often it is a slow, but pro-
gressive, crippling of the joints, with a_ disability that makes the disease one
of the most terrible of human afflictions.
394 CONSTITUTIONAL DISEASES.
In the acute febrile form, usually mistaken for rheumatic fever, moderate
doses of the salic34ates should be given, and the joints require the local meas-
ures mentioned in the section on acute rheumatism.
The treatment of the ordinary form may be considered under :
(1) Medicixal. — ISTo single remedy is of special value. General tonics
are indicated. Arsenic in full doses is helpful in some cases. The syrup of
the iodide of iron is useful, alternating with arsenic. Potassium iodide is
useful in the form ^vith much periarthritis.
(3) Gexeral Hygiene and Diet. — The disease is one of progressive de-
bility, and measures of a supporting character are indicated. Fresh air and
careful attention to personal h3'giene are most essential. The question of
diet is of the first importance. There is one rule — let the patient eat all
the good food she can digest. So many persons are afflicted not only vi^ith the
disease, but reduced by dieting, that I often find " full diet " the best pre-
scription. One has to remember that gastro-intestinal disturbances are com-
mon in the disease.
(3) Hydrotherapy. — The Hot Springs, Bath County, Va., and the Hot
Springs, Ark., in the United States, and those of Bath, England, sometimes
give very good results. Many of our cases seem to have been made much
worse by the treatment at Spas, largely, I believe, from over-use of baths
and a reducing diet. Much may be effected at home by hot-air baths, hot
baths, and compresses at night to the tender joints.
(4) Local Treatment. — Vigorous measures should be taken early. It
is a disease to be fought actively at every stage. Massage, carefully given,
reduces the peri-articular infiltrations, increases the mobility of stiffened
joints, and, most important of all, prevents the atrophy of the muscles adja-
cent to the affected joints. The hot-air treatment, thoroughly carried out,
helps many cases, and should be given a trial. Systematic exercises by the
patients are very useful.
And lastly, surgical measures may be needed. The thermo-cautery is most
useful in relieving the pain and in lessening the ligamentous thickening,
Eepeated applications are helpful along the spine in the spondylitis defor-
mans. The jacket is useful in the spinal cases until the acute symptoms are
past. Goldthwaite and others have reported good results from the breaking
up of adhesions and the use of orthopsedic appliances.
II. CHRONIC RHEUMATISM.
Etiology. — This affection may follow an acute or subacute attack, but
more commonly comes on insidiously in persons who have passed the middle
period of life. In my experience it is extremely rare as a sequence of acute
rheumatism. It is most common among the poor, particularly washer-
women, day-laborers, and those whose occupation exposes them to cold and
damp.
Morbid Anatomy. — The sjmovial membranes are injected, but there is usu-
ally not much effusion. The capsule and ligaments of the joints are thick-
ened, and the sheaths of the tendons in the neighborhood imdergo similar
alterations, so that the free play of the joint is greatly imptired. In long-
standing cases the cartilages also undergo changes, and may show erosions.
CHRONIC RHEUMATISM. 395
Even in cases with the severest symptoms, the joint may be very slightly
altered in appearance. Important changes take place in the muscles and
nerves adjacent to chronically inflamed joints, particularly in the mono-
articular lesions of the shoulder or hip. Muscular atrophy supervenes partly
from disuse, partly through nervous influences, either centric or reflex (Vul-
pian), or as a result of peripheral neuritis. In some cases when the joint is
much distended the wasting may he due to pressure, either on the muscles
themselves or on the vessels supplying them.
Symptoms. — Stiffness and pain are the chief features of chronic rheuma-
tism. The latter is very liable to exacerbations, especially during changes in
the weather. The joints may be tender to the touch and a little swollen, but
are seldom reddened. As a rule, many joints are affected; but there are
instances in which the disease is confined to one shoulder, knee, or hip. The
stiffness and pain are more marked after rest, and as the day advances the
joints may, with exertion, become much more supple. The general health
may not be seriously impaired. The disease is not immediately dangerous.
Anchylosis may occur, and ultimately the joints may become much distorted.
In many instances, particularly those in which the pain is severe, the general
health may be seriously involved and the subjects become anemic and very
apt to suffer with neuralgia and dyspepsia. Valvular lesions, due to slow
sclerotic changes, are not uncommon. They are associated with, not dependent
upon, the articular disease.
Prognosis. — The prognosis is not favorable, as a majority of the cases
resist all methods of treatment. It is, however, a disease which persists indefi-
nitely, and does not necessarily shorten life.
Treatment. — Internal remedies are of little service. It is important to
maintain the digestive functions and to keep the general health at a high
standard. Potassium iodide, sarsaparilla, and guaiacum are sometimes bene-
ficial. The salicylates are useless.
Local treatment is very beneficial. " Firing " with the Paquelin cautery
relieves the pain, and it is perhaps the best form of counter-irritation. Mas-
sage, with passive motion, helps to reduce swelling, and prevents anchylosis.
It is particularly useful in cases which are associated with atrophy of the
muscles. Electricity is not of much benefit. Climatic treatment is very
advantageous. Many cases are greatly helped by prolonged residence in
southern Europe or Southern California or by spending the winters in Egypt.
Eich patients should always winter in the South, and in this way avoid the
cold, damp weather.
Hydrotherapeutic measures are specially beneficial. Great relief is afforded
by wrapping the affected joints in cold cloths, covered with a thin layer of
blanket, and protected with oiled silk. The Turkish bath is useful, but the
full benefit of this treatment is rarely seen except at bathing establishments.
The hot alkaline waters are particularly useful, and a residence at Bath,
England, the Hot Springs of Virginia, Arkansas, or Santa Rosalia, Mexico,
or at Banff, in the Rocky Mountains, on the Canadian Pacific Railway, will
sometimes cure even obstinate cases.
396 CONSTITUTIONAL DISEASES.
III. MUSCULAR RHEUMATISM (Myalgia).
Definition. — A painful affection of the volimtary muscles and of the fasciae
and periosteum to which they are attached. The affection has received various
names, according to its seat, as torticollis, lumbago, pleurodynia, etc.
Etiology. — The attacks follow cold and exposure. It is by no means
certain that the muscular tissues are the seat of the disease. Many writers
claim, perhaps correctly, that it is a neuralgia of the sensory nerves of the
muscles. Until our knowledge is more accurate, however, it may be con-
sidered under the rheumatic affections.
It is most commonly met with in men, partieularl}- those exposed to cold
and whose occupations are laborious. It is apt to follow exposure to a draught
of air, as from an open window in a railway carriage. A sudden chilling
after heavy exertion may also bring on an attack of lumbago. Persons of a
rheumatic or gouty habit are certainly more prone to this affection. One
attack renders an Individual more liable to another. It is usually acute, but
may become subacute or even chronic.
Symptoms. — The affection is entirel}^ local. The constitutional disturb-
ance is slight, and, even in severe cases, there may be no fever. Pain is a
prominent symptom. It may be constant, or may occur only when the muscles
are drawn into certain positions. It may be a dull ache, like the pain of a
bruise, or sharp, severe, and cramp-like. It is often sufficiently intense to
cause the patient to cry out. Pressure on the affected part usually gives
relief. As a rule, myalgia is a transient affection, lasting from a few hours
to a few days. Occasionally it is prolonged for several weeks. It is very
apt to recur.
The following are the principal varieties:
(1) Lumbago, one of the most common and painful forms, affects the
muscles of the loins and their tendinous attachments. It occurs chiefl}^ in
workingmen. It comes on suddenly, and in very severe cases completely
incapacitates the patient, who may be unable to turn in bed or to rise from
the sitting posture.
( 2 ) Stiff xeck or torticollis affects, the muscles of the antero-lateral
region of the neck. It is very common, and occurs most frequently in the
young. The patient holds the head in a peculiar manner, and rotates the whole
body in attempting to turn it. Usually the attack is confined to one side.
The muscles at the back of the neck may also be affected.
(3) Pleurodyxia involves the intercostal muscles on one side, and in
some instances the pectorals and serratus magnus. This is, perhaps, the most
painful form of the disease, as the chest can not be at rest. It is more common
on the left than on the right side. A deep breath, or coughing, causes very
intense pain, and the respiratory movements are restricted on the affected
side. There may be pain on pressure, sometimes over a very limited area.
It may be difficult to distinguish from intercostal neuralgia, in which affec-
tioHj however, the pain is usually more circumscribed and paroxj^smal, and
there are tender points along the course of the nerves. It is sometimes mis-
taken for pleurisy, but careful physical examination readily distinguishes
between the two affections.
GOUT. 397
(4) Among other forms which may be mentioned are cephalodynia,
affecting the muscles of the head ; scapulodynia, omodynia, and dorsodynia,
affecting the muscles about the shoulder and upper part of the back. Myal-
gia may also occur in the abdominal muscles and in the muscles of the
extremities.
Treatment. — Rest of the affected muscles is of the first importance. Strap-
ping the side will sometimes completely relieve pleurodynia. No belief is
more wide-spread among the public than in the efficacy of porous plasters, for
muscular pains vi all sorts, particularly those about the trunk. If the pain
is severe and agonizing, a hypodermic of morphia gives immediate relief.
For lumbago acupuncture is, in acute cases, the most efficient treatment.
Needles of from three to four inches in length (ordinary bonnet- needles,
sterilized, will do) are thrust into the lumbar muscles at the seat of the pain,
and withdrawn after five or ten minutes. In many instances the relief is
immediate, and I can corroborate fully the statements of Einger, who taught
me this practice, as to its extraordinary and prompt efficacy in many in-
stances. The constant current is sometimes very beneficial. In many forms
of myalgia the thermo-cautery gives great relief. In obstinate cases blisters
may be tried. Hot fomentations are soothing, and at the outset a Turkish
bath may cut short the attack. In chronic cases potassium iodide may be
used, and both guaiacum and sulphur have been strongly recommended. Per-
sons subject to this affection should be warmly clothed, and avoid, if possible,
exposure to cold and damp. In gouty persons the diet should be restricted
and the alkaline mineral waters taken freely. Large doses of nux vomica
are sometimes beneficial.
IV. GOUT (Podagra).
Definition. — A nutritional disorder, one factor of which is an excess of
uric acid in the circulating blood, characterized clinically by attacks of acute
arthritis, by the gradual deposition of sodium biurate in and about the joints,
and by the occurrence of irregular constitutional symptoms.
Etiology. — The precise nature of the disturbance in metabolism is not
known. There is probably defective oxidation of the foodstuffs, combined
with imperfect elimination of the waste products of the body.
(1) Predisposing Etiological Factors. — Hereditary Influences. — Sta-
tistics show that in from 50 to 60 per cent of all cases the disease existed in
the parents or grandparents. The transmission is supposed to be more marked
from the male side. Cases with a strong hereditary taint have been knoM^n
to occur before puberty. The disease has been seen even in infants at the
breast. Males are more subject to the disease than females. It rarely is seen
before the thirtieth year, and in a large majority of the cases the first mani-
festations appear before the age of fifty.
Alcohol is the most potent factor in the etiology of the disease. Fer-
mented liquors favor its occurrence much more than distilled spirits, and it
prevails most extensively in countries like England and Germany, which con-
sume the most beer and ale. The lighter beers used in this country are much
less liable to produce gout than the heavier English and Scotch ales. Many
cases occur in bartenders and brewery men.
398 CONSTITUTIONAL DISEASES.
Food plaj^s a role equal in importance to that of alcohol. Overeating
without active bodily exercise is regarded as a very special predisposing cause.
A form of gouty dyspepsia has been described. A robust and active digestion
is, however, often met in gouty persons. Gout is by no means confined to
the rich. In England the combination of poor food, defective hygiene, and
an excessive consumption of malt liquors makes the " poor man's gout " a
common affection.
Lead. — Garrod has shown that workers in lead are specially prone to gout.
In 30 per cent of the hospital cases the patients had been painters or workers
in lead. The association is probably to be sought in the production by this
poison of arterio-sclerosis and chronic nephritis. In the United States,
chronic lead-poisoning is frequently associated with arterio-sclerosis and con-
tracted kidneys, but lead-gout is comparatively rare. Gouty deposits are,
however, to be found in the big-toe joint and in the kidneys in cases of
chronic plumbism.
The colored race does not escape. Of 59 cases of gout admitted to the
medical wards of the Johns Hopkins Hospital up to April 1, 1905, 3 were
in negroes. In two the diagnosis was confirmed at autopsy and in the third
by the presence of tophi in the ears. Only 2 of the 59 were females.
(2) ExciTixG Causes. — ^AVorry or a sudden mental shock may bring on
an attack within ten or twelve hours. In susceptible persons a slight injury
or an accident of any sort or a surgical operation may be followed by an acute
arthritis.
(3) Metabolic Causes. — The nature of gout is unlmown. That there
is faulty metabolism, associated in some very special way with the chemistry
of uric acid, we know, but nothing more. The remainder is theory, awaiting
refutation or confirmation. Notwithstanding attempts to minimize the im-
portance of uric acid as a factor, until more convincing evidence to the con-
trar}' is advanced we must adhere to the uric acid theor}^ The conditions
of life favorable to the development of gout are present in too many of us
after the middle period of life — more fuel in the form of meat and drink
than the machine needs — the condition which Francis Hare describes as hj^er-
pjTsemia. G. B. Balfour puts it well when he says : '^ The gouty diathesis is
only a comprehensive term for all those changes in the character and com-
position of the blood induced by the evils of civilization — deficient exercise
and excess of nutriment. . . . Gout, on the other hand, is the name given
to all those modifications of our metabolism caused by the gouty diathesis,
as well as to all the symptoms to which those modifications give rise.''
The views regarding uric acid and its relation to gout are very numerous.
Although we are still ignorant of the actual seat of formation of uric acid,
yet its source has been pretty accurately determined. It constitutes one of the
" purin " bodies of Fischer, the xanthin or nuclein bases comprising the re-
mainder. All are closely related chemically. Horbaczewski and others have
demonstrated that uric acid is largely, if not entirely, derived from nuclein
resulting from nuclear disintegration. According to Burian and Schur, the
uric acid formed in the system is from two sources. The " endogenous " uric
acid is derived from the nucleins of the body, while the " exogenous " uric acid
is formed from the nucleins of the ingested food. The uric acid derived from
the intake of exogenous oxj'purins (nucleo-proteids) constitutes from 40 to
GOUT. 399
60 per cent of the total purin content of the body. We do not know in what
form uric acid exists in the circulating blood. It is not as uric acid itself.
Bence Jones, and Eoberts held that it occurs as a very soluble quadriurate
consisting of a molecule of uric acid in loose combination with an acid urate
molecule. Many think that such a compound is not capable of existing in
a medium with a composition such as the blood has. Minkowski claims that
it exists normally in the blood in organic combination with nucleotin-phos-
phoric acid. Garrod was the first to point out that there was an excess of
uric acid in the blood. This is about the only feature of the disease on which
there seems general agreement. Magnus-Levy made 34 analyses in 17 cases
of gout and found the uric acid in the blood to range between 0.021 and 0.10
grams in 1,000 cc. It has not been definitely established that the amount is
increased during the acute attack. Of the three possible causes for this
increase — increased formation, diminished destruction or oxidation, and di-
minished excretion — the balance of evidence favors the latter. Schmoll found
that there is a nitrogen retention in gout, which supports this view. Min-
kowski and His believe that in gouty individuals the uric acid circulates
in the blood in a different organic combination than in the blood of
healthy persons, and that consequently the kidneys are functionally in-
capable of eliminating it as in normal conditions. The studies of the
alkalinity of the blood, even with the most modern methods, are very conflict-
ing. Magnus-Levy's investigations seem to show that there is no constant
diminution in the alkalinity of the blood in gout, also that there is no greater
diminution in the alkalinity during the acute attacks than in the intervals.
The methods of determining the alkalinity of the blood are notoriously inac-
curate. It has been held that the uric acid excess in the blood is due to
deficient alkalinity, thus preventing solubility and easy excretion of the uric
acid. There is now no evidence to support this view. The recent electro-
potential measurements of Fakkas, Fraenkel, and Hoeber seem to show that
the reaction of the blood normally is neutral and not alkaline.
The excretion of uric acid by a healthy individual on an average mixed
diet ranges normally between 0.4 and 1.0 gramme daily. Hammarsten gives
the average as 0.7 gramme. Of the total purin or alloxuric bodies of the urine,
nine-tenths exist as uric acid and one-tenth as the purin or xanthin bases.
Quantitative determinations show that the excretion of uric acid in gout is
usually far below the lower limit for normal in the intervals between attacks,
particularly just before an acute exacerbation. With the onset of an acute
attack the excretion gradually increases until in three or four days the amount
of uric acid may reach or occasionally exceed the upper limit for normal.
The cause of this increase is not clear. Quantitative determinations of uric
acid in the blood show no constant increase in the uric acid during the acute
attacks, nor has there been found any constant variation in the chemical reac-
tion of the blood at this time.
Garrod holds that with lessened alkalinity of the blood there is an increase
in the uric acid, due chiefly to diminished elimination. He attributes the
deposition of the sodium urate to the diminished alkalinity of the plasma,
which is unable to hold it in solution. In an acute paroxysm there is an
accumulation of the urates in the blood, and the inflammation is caused
by their sudden deposit in crystalline form about the joint.
400 CONSTITUTIONAL DISEASES.
Haig thinks that there is no increased formation of uric acid in gout, but
tliat the blood is less alkaline than normal^ and less able to hold the uric
acid or its salts in solution.
According to Sir William Roberts, owing to deficient elimination the
soluble quadriurate accumulates in the blood. This quadriurate, circulating
in a medium rich in sodium carbonate, takes on an additional atom of the
base and becomes converted into the insoluble biurate, which becomes depos-
ited in the tissues, particularly about the joints.
Ebstein thinks that the first change is a nutritive tissue disturbance, which
leads to necrosis, and in the necrotic areas the urates are deposited — a view
which has been modified by von Noorden, who holds that a special ferment
leads to the tissue change, to which the deposit of the urates is secondary.
Ebstein designates these as " primary Joint-gout " cases. Most cases belong
to this group. He also describes what he terms " primary kidney -gout "
cases. Owing to primary disease of the kidneys the uric acid is not properly
eliminated and secondary joint manifestations ensue. These cases are rare,
and he states that they must not be confused with the secondary nephritis.
Cullen held that gout was primarily an affection of the nervous system.
On this nervous theory of gout there is a basic, arthritic stock — a diathetic
habit, of which gout and rheumatism are two distinct branches. The gouty
diathesis is expressed in (a) a neurosis of the nerve-centres, which may be
inherited or acquired; and (&) "a peculiar incajDacit}^ for normal elaboration
within the whole body, not merely in the liver or in one or two organs, of
food, whereby uric acid is formed at times in excess, or is incapable of being
duly transformed into more soluble and less noxious products" (Duckworth).
The explosive neuroses and the influence of depressing circumstances, physical
or mental, point strongh' to the part played by the nervous system in the
disease. For a full discussion of the various theories and an elaborate consid-
eration of the clinical chemistry of the subject the reader is referred to von
ISToorden's Treatise on Diseases of Metabolism (English edition) and to
Futcher's article in m}" System of Medicine.
Morbid Anatomy. — The hJood is stated to have an excess of uric acid. It
may be obtained from the blood-serum by the method known as Garrod's
uric-acid thread experiment, or from the serum obtained from a blister. To
3 ij of serum add TIX v-vj of acetic acid in a watch-glass. A thread immersed
in this may show in a few hours an incrustation of uric acid. The experi-
ment is rarely successful even in cases of manifest gout. This excess, also,
is not peculiar to gout, but occurs in leukgemia and chlorosis.
The " perinuclear basophilic granules " about the nuclei of the leucocytes,
described b}" Xeusser in 1894 and regarded by him as practically pathogno-
monic of gout or a gouty diathesis, were subsequently shown to be artifacts
produced during the process of staining. The red cells in the " lead-gout "
cases may show basophilic granular staining.
The important changes are in the articular tissues. The first joint of the
great toe is most frequently involved; then the ankles, knees, and the small
joints of the hands and wrists. The deposits may be in all the joints of the
lower limbs and absent from those of the upper limbs (ISTorman Moore). If
death takes place during an acute paroxysm, there are signs of inflammation,
hypersemia, swelling of the ligamentous tissues, and of effusion into the joint.
GOUT. 401
The primary change, according to Ebstein, is a local necrosis, due to the
presence of an excess of urates in the blood. This is seen in the cartilage
and other articular tissues in which the nutritional currents are slow. His
and Mordhorst hold that the deposition of the urates is primary, and that
the tissue necrosis takes place as a result of this deposit. In these areas of
coagulation necrosis the reaction is always acid and the neutral urates are
deposited in crystalline form, as insoluble acid urate. The articular cartilages
are first involved. The gouty deposit may be uniform, or in small areas.
Though it looks superficial, the deposit is invariably interstitial and cov-
ered by a thin lamina of cartilage. The deposit is thickest at the part most
distant from the circulation. The ligaments and fibro-cartilage ultimately
become involved and are infiltrated with biurate deposits, the so-called chalk-
stones, or tophi. These are usually covered by skin; but in some cases, par-
ticularly in the metacarpo-phalangeal articulations, this ulcerates and the
chalk-stones appear externally. The synovial fluid may also contain crystals.
In very long-standing cases, owing to an excessive deposit, the joint becomes
immobile. The marginal outgrowths in gouty arthritis are true exostoses
(Wynne). The cartilage of the ear may contain tophi, which are seen as
whitish nodules at the margin of the helix. The cartilages of the nose,
eyelids, and larynx are less frequently affected. Somewhat analogous to
these tophi in man are the deposits characterizing the "guanin gout" of
hogs. Under certain conditions in pigs one sees in the muscles, liga-
ments, and articular tissues small whitish deposits which are made up of
guanin. These are frequently seen in the Smithfield and Westphalian
hams.
Of changes in the internal organs, those in the renal and vf-scular systems
are the most important. The kidney changes believed to be characteristic
of gout are: (a) A deposit of urates chiefly in the region of the papillae.
This, however, is less common than is usually supposed. Norman Moore
found it in only 13 out of 80 cases. The apices of the pyramids show lines
of whitish deposit. On microscopical examination the material is seen to be
largely in the intertubular tissue. In some instances, however, the deposit
seems to be both in the tissue and in the tubules. Ebstein has described and
figured areas of necrosis in both cortex and medulla, in the interior of which
were crystalline deposits of urate of soda. The presence of these uratic con-
cretions at the apices of the pyramids is not a positive indication of gout.
( & ) An interstitial nephritis, either the ordinary " contracted kidney " or the
arterio-sclerotic form, neither of which is in any way distinctive. It is not
possible to say in a given case that the condition has been due to gout unless
marked evidences of the disease coexist.
The metatarso-phalangeal joint of the big toe should be carefully exam-
ined, as it may show typical lesions of gout without any outward token of
arthritis.
Arterio-sclerosis is a very constant lesion. With it the heart, particularly
the left ventricle, is found hyper trophied. According to some authors, con-
cretions of urate of soda may occur on the valves. Myocarditis is a frequent
occurrence in chronic cases.
Changes in the respiratory system are rare. Deposits have been found in
the vocal cords, and uric-acid crystals have been met in the sputa of a gouty
27
402
CONSTITUTIONAL DISEASES.
patient (J. W. Moore). Emphysema is a very constant condition in old
cases.
Symptoms, — Gont is usually divided into acute, chronic, and irregular
forms.
Acute Gout. — Premonitory symptoms are common — twinges of pain in
the small joiats of the hands or feet, nocturnal restlessness, irritability of
Grms.
JANUARY
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Chart XIV. — Showing Uric Acid and Phosphoric Acid Output in Case of Acute Govt.
temper, and dyspepsia. The urine is acid, scanty, and high-colored. It de-
posits urates on cooling, and there may be, according to Garrod, transient
albuminuria. There may be traces of sugar (gouty glycosuria). Before an
GOUT. 403
attack the output of uric acid is low and is also diminished in the early part
of the paroxysm. The relation of uric and phosphoric acids to the acute
attacks is well represented in Chart XIV, prepared by Futcher. Both were
extremely low in the intervals, but reached within normal limits shortly after
the onset of the acute symptoms. The phosphoric acid and uric acid show
almost parallel curves. The patient was on a very light fixed diet at the
time the determinations were made. Bain holds that the phosphoric .acid
excretion varies directly with that of the uric acid. Watson claims that there
is no relationship between the two. In some instances the throat is sore, and
there may be asthmatic symptoms. The attack sets in usually in the early
morning hours. The patient is aroused by a severe pain in the metatarso-
phalangeal articulation of the big toe, and more commonly on the right than
on the left side. The pain is agonizing, and, as Sydenham says, " insinuates
itself with the most exquisite cruelty among the numerous small bones of the
tarsus and metatarsus, in the ligaments of which it is lurking." The joint
swells rapidly, and becomes hot, tense, and shiny. The sensitiveness is ex-
treme, and the pain makes the patient feel as if the joint were being pressed
in a vise. There is fever, and the temperature may rise to 103° or 103°.
Toward morning the severity of the symptoms subsides, and, although the
joint remains swollen, the day may be passed in comparative comfort. The
symptoms recur the next night, and the fit, as it is called, usually lasts for
from five to eight days, the severity of the symptoms gradually abating. There
is usually a moderate leucocytosis during the acute manifestations. Occasion-
ally other joints are involved, particularly the big toe of the opposite foot.
The inflammation, however intense, never goes on to suppuration. With the
subsidence of the swelling the skin desquamates. After the attack the general
health may be much improved. As Aretaeus remarks, a person in the interval
has won the race at the Olympian games. Eecurrences are frequent. Some
patients have three or four attacks in a year ; others suffer at longer intervals.
The term retrocedent or suppressed gout is applied to serious internal
symptoms, coincident with a rapid disappearance or improvement of the local
signs. Very remarkable manifestations may occur under these circumstances.
The patient may have severe, gastro-intestinal symptoms — pain, vomiting, diar-
rhoea, and great depression — and death may occur during such an attack. Or
there may be cardiac manifestations — dyspnoea, pain, and irregular action
of the heart. In some instances in which the gout is said to attack the heart,
an acute pericarditis proves fatal. So, too, there may be marked cerebral
manifestations — delirium or coma, and even apoplexy — but in a majority of
these instances the symptoms are, in all probability, urasmic.
Gout in America. — While not so common as in England and Germany,
the disease is by no means infrequent, and is perhaps on the increase. It is
only one-third less' frequent at the Johns Hopkins Hospital than at Saint
Bartholomew's Hospital. It is more common among the lower classes, who
drink beer, than among the well-to-do, who have become of late much more
temperate. Among about 18,000 cases in my wards there were 59 cases of
gout. All were whites but three, and all males but two (Futcher).
Chronic Gout. — With increased frequency in the attacks, the articular
symptoms persist for a longer time, and gradually many joints become affected.
Deposits of urates take place, at first in the articular cartilages and then in
404 CONSTITUTIONAL DISEASES.
the ligaments and capsular tissues; so that in the course of years the joints
become swollen, irregular, and deformed. The feet are usually first affected,
then the hands. In severe cases there may be extensive concretions about the
elbows and knees and along the tendons and in the bursse. The tophi appear
in the ears. Finally, a unique clinical picture is produced which can not be
mistaken for that of any other affection. The skin over the tophi may rupture
or ulcerate, and about the knuckles the chalk-stones may be freely exposed.
Patients with chronic gout are usually dyspeptic, often of a sallow complexion,
and show signs of arterio-sclerosis. The pulse tension is increased, the vessels
are stiff, and the left ventricle is hypertrophied. The urine is increased in
amount, is of low specific gravity, and usually contains a slight amount of
albumin, with a few hyaline casts. Severe cramps involving the calf, abdom-
inal, and thoracic muscles may occur. Intercurrent attacks of acute poly-
arthritis may develop, in which the joints become inflamed, and the tempera-
ture ranges from 101° to 103°, There may be pain, redness, and swelling of
several joints without fever. Ursemia, pleurisy, pericarditis, peritonitis, and
meningitis are common terminal affections. The victim of gout may show
remarkable mental and even bodily vigor. Certain of the most distinguished
members of our profession have been terrible sufferers from this disease,
notably the elder Scaliger, Jerome Cardan, and Sydenham, whose statement
that " more wise men than fools are victims of the affection " still holds
good.
Irregular Gout. — This is a motley, ill-defined group of symptoms, mani-
festations of a condition of disordered nutrition, to which the terms gouty
diathesis or litlicemic state have been given. Cases are seen in members of
gouty families, who may never themselves have suffered from the acute dis-
ease, and in persons who have lived not wisely but too well, who have eaten
and drunk largely, lived sedentary lives, and yet have been fortunate enough
to escape an acute attack. It is interesting to note the various manifestations
of the disease in a family with marked hereditary disposition. The daughters
often escape, while one son may have gouty attacks of great severity, even
though he lives a temperate life and tries in every way to avoid the conditions
favoring the disorder. Another son has, perhaps, only the irregular mani-
festations and never the acute articular affection. While the irregular features
are perhaps more often met with in the hereditary affection, they are by no
means infrequent in persons who appear to have acquired the disease. The
tendency in some families is to call every affection gouty. Even infantile
complaints, such as scald-head, naso-pharyngeal vegetations, and enuresis, are
often regarded, without sufficient grounds, I believe, as evidences of the family
ailment. Among the commonest manifestations of irregular gout are the
following :
(fl) Cutaneous Eruptions. — Garrod and others have called special atten-
tion to the frequent association of eczema with the gouty habit. The French
in particular insist upon the special liability of gouty persons to skin affec-
tions, the artliritides, as they call them.
(6) Gastro-intestinal Disorders. — Attacks of what is termed biliousness,
in which the tongue is furred, the breath foul, the bowels constipated, and
the action of the liver torpid, are not uncommon in gouty persons. A gouty
parotitis is described.
GOUT. 405
(c) Cardio-vascular Symptoms. — With the lithaBmia, arterio-sclerosis is
frequently associated. The blood tension is persistently high, the vessel walls
become stiff, and cardiac and renal changes gradually occur. In this condition
the manifestations may be renal, as when the albuminuria becomes more
marked, or dropsical symptoms supervene. The manifestations may be car-
diac, when the hypertrophy of the left ventricle fails and there are palpitation,
irregular action, and ultimately a condition of asystole. Or, finally, the mani-
festations may be vascular, and thrombosis of the coronary arteries may cause
sudden death. Aneurism may occur and prove fatal, or, as most frequently
happens, a blood-vessel gives way in the brain, and the patient dies of apo-
plexy. It makes but little difference whether we regard this condition as
primarily an arterio-sclerosis, or as a gouty nephritis; the point to be remem-
bered is that the nutritional disorder with which an excess of uric acid is
associated induces in time increased tension, arterio-sclerosis, chronic inter-
stitial nephritis, and change's in the myocardium. Pericarditis is not an
infrequent terminal complication of gout. Phlebitis occasionally occurs.
(d) Nervous Manifestations. — Headache and megrim attacks are not in-
frequent. Haig attributes them to an excess of uric acid. Neuralgias are not
uncommon; sciatica and parsesthesias may develop. A common gouty mani-
festation, upon which Duckworth has laid stress, is the occurrence of hot or
itching feet at night. Plutarch mentions that Strabo called this symptom
" the lisping of the gout." Cramps in the legs may also be very troublesome.
Hutchinson has called attention to hot and itching eyeballs as a frequent sign
of masked gout. Associated or alternating with this symptom there may be
attacks of episcleral congestion. Apoplexy is a common termination of gout.
Meningitis may occur, usually basilar.
(e) Urinary Disorders. — The urine is highty acid and high-colored, and
may deposit on standing crystals of uric acid. Transient and temporary
increase in this ingredient can not be regarded as serious. In many cases of
chronic gout the amount may be diminished, and increased only at certain
periods, forming the so-called uric-acid showers. The chart on page 403
illustrates this very well. A sediment of uric acid in a urine does not
necessarily mean an excess. It is often dependent on the inability of the
urine to hold it in solution. Sugar is found intermittently in the urine of
gouty persons — gouty glycosuria. It may pass into true diabetes, but is usually
very amenable to treatment. Oxaluria may also be present. Gouty persons
are specially prone to calculi, Jerome Cardan to the contrary, who reckoned
freedom from stone among the chief of the dona podagrce. Minute quantities
of albumin are very common in persons of gouty dyscrasia, and, when the
renal changes are well established, tube-casts. Urethritis, with a purulent
discharge, may arise, so it is stated, usually at the end of an attack. It may
occur spontaneously, or follow a pure connection.
(f) Pulmonary Disorders. — There are no characteristic changes, but, as
Greenhow has pointed out, chronic bronchitis occurs with great frequency in
persons of a gouty habit.
(g) Of eye affections, iritis, glaucoma, hgemorrhage retinitis, and sup-
purative panophthalmitis have been described.
Diagnosis. — Recurring attacks of arthritis, limited to the big toe and to
the tarsus, occurring in a member of a gouty family, or in a man who has
406 CONSTITUTIONAL DISEASES.
lived too well, leave no question as to the nature of the trouble. There are
many cases of gout, however, in which the feet do not suffer most severely.
After an attack or two in one toe, other joints may be affected, and it is
just in such cases of polyarthritis that the difficulty in diagnosis is apt to
arise. We have had of late years several cases admitted for the third or fourth
time with involvement of three or more of the larger joints. The presence
of tophi has settled the nature of a trouble which in the previous attacks had
been regarded as rheumatic. The following are suggestive points in such
ca^es: (1) The patient's habits and occupation. In the United States the
brewery men and barkeepers are often affected. (2) The presence of tophi.
The ears should alwaj's be inspected in a case of polyarthritis. The diagnosis
may rest with a small tophus. The student should learn to recognize on the
ear margin, Woolner's tip, fibroid nodules, and small sebaceous tumors. The
last are easily recognized microscopically. The needle-shaped sodium biurate
crystals are distinctive of the tophi. (3) The condition of the urine. As
shown in Chart XIY, the uric-acid output is usually very low during the inter-
vals of the paroxysm. At the height of the attack the elimination, as a rule,
is greatly increased. The ratio of the uric acid to the urea excretion is dis-
turbed in gouty cases, and may fall as low as 1 to 100 or 1 to 150. (4) The
gouty polyarthritis may be afebrile. A patient with three or four joints red,
swollen, and painful in acute rheumatism has fever, and, while pyrexia may
be present and often is in gout, its absence is, I think, a valuable diagnostic
sign. Many cases go a-begging for a diagnosis. A careful study of the
patient's habits as to beer drinking, of the location of the initial arthritic
attacks, and the examination for tophi in the ears will prevent many cases
being mistaken for rheumatism or arthritis deformans.
Treatment, — Hygiexic. — Individuals who have inherited a tendency to
gout, or who have shown any manifestations of it, should live temperately,
abstain from alcohol, and eat moderately. An open-air life, with plenty of
exercise and regular hours, does much to counteract an inborn tendency to
the disease. The skin should be kept active: if the patient is robust, by the
morning cold bath with friction after it ; but if he is weak or debilitated the
evening warm bath should be substituted. An occasional Turkish bath with
active shampooing is very advantageous. The patient should dress warmly,
avoid rapid alterations in temperature, and be careful not to have the skin
suddenly chilled.
Dietetic. — With few exceptions, persons over forty eat too much, and
the first injunction to a gouty person is to keep his appetite within reasonable
bounds, to eat at stated hours, and to take plenty of time at his meals. In
the matter of food, quantity is a factor of more importance than quality with
many gouty persons. As Sir William Eoberts well says, " N'owhere perhaps
is it more necessary than in gout to consider the man as well as the ailment,
and very often more the man than the ailment."
Very remarkable differences of opinion exist as to the most suitable diet
in this disease, some urging warmly a vegetable diet, others allowing a very
liberal amount of meat. On the one hand, the author just quoted says : " The
most trustworthy experiments indicate that fat, starch, and sugar have not
the least direct influence on the production of uric acid; but as the free con-
sumption of these articles naturally operates to restrict the intake of the
GOUT. 407
nitrogenous food, their use has indirectly the effect of diminishing the aver-
age production of uric acid." On the other hand, W. H. Draper says : " The
conversion of azotized food is more complete with a minimum of carbohydrates
than it is with an excess of them; in other words, one of the best means of
avoiding the accumulation of lithie acid in the blood is to diminish the carbo-
hydrates rather than the azotized foods." The weight of opinion leans to the
use of a modified nitrogenous diet, without excess in starchy and saccharine
articles of food. Animal foods rich in nuclear material, such as sweetbfeads,
liver, kidneys, and brain, should be avoided. Beef extracts are injurious, owing
to their richness in extractives belonging to the xanthin group. Milk and eggs
are particularly useful, owing to their not containing any nuclein. Fresh
vegetables and fruits may be used freely, but among the latter strawberries
and bananas should be avoided.
Ebstein urges strongly the use of fat in the form of good fresh butter,
from 2^ to d^ ounces in the day. He says that stout gouty subjects not only
do not increase in weight with plenty of fat in the food, but that they actually
become thin and the general condition improves very much. Hot bread of
all sorts and the various articles of food prepared from Indian corn should,
as a rule, be avoided. Eoberts advises gouty patients to restrict as far as
practicable the use of common salt with their meals, since the sodium biurate
very readily crystallizes out in tissues with a high percentage of sodium salts.
In this matter of diet each individual case must receive separate con-
sideration.
There are very few conditions in the gouty in which stimulants of any
sort are reqnired. Whenever indicated, whisky will be found perhaps the
most serviceable. While all are injurious to these patients, some are much
more so than others, particularly malted liquors, champagne, port, and a very
large proportion of all the light wines.
Mineral Waters. — All forms may be said to be beneficial in gout, as the
main element is the water, and the ingredients are usually indifferent. Much
of the humbuggery in the profession still lingers about mineral waters, more
particularly about the so-called lithia waters.
The question of the utility of alkalies in the treatment of gout is closely
connected with this subject of mineral waters. This deep-rooted belief in the
profession was rudely shaken a few years ago by Sir William Roberts, who
claims to have shown conclusively that alkalescence as such has no influence
whatever on the sodium biurate. The sodium salts are believed by this author
to be particularly harmful, but, in spite of all the theoretical denunciation
of the use of the sodium salts in gout, the gouty from all parts of the world
flock to those very Continental springs in which these salts are most predomi-
nant. Bain urges the use of potassium salts.
Of the mineral springs best suited for the gouty may be mentioned, in the
United States, those of Saratoga, Bedford, and the White Sulphur; Buxton
and Bath, in England; in France, Aix-les-Bains and Contrexeville ; and in
Germany, Carlsbad, Wildbad, and Homburg.
The efficacy in reality is in the water, in the way it is taken, on an empty
stomach, and in large quantities; and, as every one knows, the important
accessories in the modified diet, proper hours, regular exercise, with baths,
douches, etc., play a very important role in the " cure."
408 CONSTITUTIONAL DISEASES.
Medicinal Treatmext. — In an acute attack the limb should be elevated
and the aflPected joint wrapped in cotton-wool. Warm fomentations, or
Fiiller's lotion, may be used. The local hot-air treatment may be tried. A
brisk mercurial purge is always advantageous at the outset. The wine or
tincture of eolchicum, in doses of 20 to 30 minims, may be given every four
hours in combination with the citrate of potash or the citrate of lithium.
The action of the eolchicum should be carefully watched. It has, in a major-
ity of the cases, a powerful influence over the symptoms — ^relieving the pain,
and reducing, sometimes with great rapidity, the swelling and redness. It
should be promptly stopped so soon as it has relieved the pain. In cases in
which the pain and sleeplessness are distressing and do not yield to colchicimi,
morphia is necessary. The patient should be placed on a diet chiefly of milk
and barley-water, but if there is any debility, strong broths may be given, or
eggs. It is occasionally necessary to give small quantities of stimulants.
During convalescence meats and fish and game may be taken, and gradually
the patient may resume the diet previously laid down.
In some of the subacute intercurrent attacks of arthritis in old, deformed
joints, the sodium salicylate is occasionally useful, but its administration must
be watched in cases of cardiac and renal insufficiency. It is also much advo-
cated by Haig in the uric-acid habit.
The chronic and irregular forms of gout are best treated by the dietetic
and hygienic measures already referred to. Potassium iodide is sometimes
useful, and preparations of guaiacum, quinine, and the bitter tonics combined
vdth alkalies are undoubtedly of benefit.
Piperazin has been much lauded as an efficient aid in the solution of uric
acid. The clinical results, however, are very discordant. It may be employed
in doses of from 15 to 30 grains in the day, and is conveniently given in
aerated water containing 5 grains to the tumblerful. Piperazin, as a uric
acid solvent, was rapidly followed by lysidin, urotropin, urea, and urol among
others — a sure indication of their therapeutic worthlessness. .
Albu speaks favorably of lemon-juice as a remedy. The vegetable acids
are converted in the system into alkaline carbonates, thus enabling the blood
to keep the uric acid compounds in solution, and consequently facilitating
their elimination by the kidneys.
Where the arthritic attacks are confined to one joint, such as the great-toe
joint, surgical interference may be considered. Eiedel reports two successful
cases in which he removed the entire joint capsule of the big-toe joint, with
permanent relief.
V. DIABETES MELLITUS.
Definition. — A disorder of nutrition, in which sugar accumulates in the
blood and is excreted in the urine, the daily amount of which is greatly
increased.
For a case to be considered one of diabetes mellitus it is necessary
that the form of sugar eliminated in the urine be grape sugar, that it
must be eliminated for weeks, months, or years, and that the excretion of
sugar must take place after the ingestion of moderate amounts of carbo-
hydrates.
DIABETES MELLITUS. 409
Etiology. — Incidence. — According to recent statistics diabetes appears
about as frequent in the United States as in European countries. The last
census gave 9.3 deaths per 100,000 population in the former compared with
from 5 to 14 in the latter. In England and Wales the death-rate from
diabetes in 1903 was 8.7 per 100,000 of population. The death-rate has been
gradually on the increase in Paris during the last three or four decades,
reaching 14 to the 100,000 of population in 1891. The disease is gradually
■on the increase in the United States. The statistics for 1870 gave 2.1 ; for
1880, 2.8 ; for 1890, 3.8 ; and for 1900, 9.3 deaths to the 100,000 population.
This apparent increase may be in part due to more accurate vital statistics
records. In this region the incidence of the disease may be gathered from
the fact that among 99,000 patients admitted to the medical wards and medi-
cal dispensary of the Johns Hopkins Hospital in nearly sixteen years there
were 226 cases of diabetes, or 0.22 per cent. Among 18,000 ward cases there
were 147 diabetics.
Hereditary influences play an important role, and cases are on record of
its occurrence in many members of the same family. Morton, who calls the
■disease hydrops ad matulam (Phthisiologia, 1689) records a remarkable family
in which four children were affected, one of whom recovered on a milk diet
and diascordium. An analysis of the cases in my series gave only 6 cases
with a history of diabetes in relatives (Pleasants). Naunyn obtained a fam-
ily history of diabetes in 35 out of 201 private cases, but in only 7 of 157 hos-
pital cases. There are instances of the coexistence of the disease in man and
wife. Among 516 married pairs collected by Senator, in which either hus-
l)and or wife was diabetic, in 18 cases the second partner had become diabetic.
It is not easy to explain this conjugal diabetes. The suggestion of contagion
seems scarcely tenable.
8ex. — Men are more frequently affected than women, the ratio being about
three to two. Up to April 1, 1905, 226 cases of diabetes had been treated
in the medical wards and medical dispensary of the Johns Hopkins Hospital,
131 of which were in males and 95 in females (Futcher). It is a disease of
adult life; a majority of the cases occur from the third to the sixth decade.
Of the 226 cases, the largest number — 63, or 27 per cent — occurred between
fifty and sixty years of age. These figures agree fairly closely with those of
Frerichs, Seegen, and Pavy, all of whom found the largest number of cases
in the sixth decade, their percentages being 26, 30, and 30.7 respectively. It
is rare in childhood, but cases are on record in children under one year
■of age.
In the above series there were no cases in the first hemi-decade, 2 in the
second, 7 in the third, and 6 in the fourth.
Persons of a neurotic temperament are often affected. It is a disease of
the higher classes. Von ^oorden states that the statistics for London and
Berlin show that the number of cases in the upper ten thousand exceeds that
in the lower hundred thousand inhabitants.
Race. — Hebrews seem especially prone to it; one-fourth of Frerichs' pa,-
tients were of the Semitic race. I have been much impressed with the fre-
quency of the disease among them. Diabetes is comparatively rare in the
colored race, but not so uncommon as was formerly supposed. Of the series
■of 226 cases, 23, or 11.3 per cent, were in negroes. The ratio of males to
28
410 CONSTITUTIONAL DISEASES.
females affected is almost exactly the reverse of that in the white race; 15
of the 23 were in females and 8 in males.
Olesity. — In a considerable proportion of the cases of diabetes the sub-
jects have been excessively fat at the beginning of, or prior to, the onset of
the disease. A slight trace of sugar is not very uncommon in obese persons.
This so-called lipogenic glycosuria is not of grave significance, and is only
occasionally followed by true diabetes. On the other hand, as von Noorden
has shown, there may be a " diabetogenous obesity," in which diabetes and
obesity develop in early life, and these cases are very unfavorable. There
are instances on record in which obesity with diabetes has occurred in
three generations. Diabetes is more common in cities than in country
districts. Gout, S3^philis, and malaria have been regarded as predisposing
causes.
Nervous Influences. — Mental shock, severe nervous strain, and worry pre-
cede many cases. In one case the symptoms came on suddenly after the
patient had been nearly suffocated by smoke from having been confined in a
cell of a burning jail. Shock and the toxic effects of the smoke may both
have been factors in this case. The combination of intense application to
business, over-indulgence in food and drink, with a sedentary life, seems
particularly prone to induce the disease. Glycosuria may set in during preg-
nancy, and in rare instances may only occur at this period. Trousseau
thought that the offspring of phthisical parents were particularly prone to
diabetes.
Injury to or disease of the spinal cord or brain has been followed by
diabetes. In the carefully analyzed cases of Frerichs there were 30 instances
of organic disease of these parts. The medulla is not always involved. In
only 4 of his cases, which showed organic disease, was there sclerosis or other
anomaly of this part. An irritative lesion of Bernard's diabetic centre in the
medulla is an occasional cause. I saw with Eeiss, at the Friedrichshain,
Berlin, a woman who had anomalous cerebral symptoms and diabetes, and
in whom there was found post mortem a C3'sticercus in the fourth ventricle.
Glycosuria sometimes occurs in tumors of the hypophysis such as accompany
acromegaly. Ebstein has recorded 4 cases in which there was a coincident
occurrence of epilepsy and diabetes mellitus. He thinks that in the majority
of cases the two diseases are dependent on a common cause. He believes that
the association would be found much more commonly in Jacksonian epilepsy
than has been the case heretofore, if more careful and systematic examina-
tions of the urine were made. A transitory glycosuria occasionally follows
cerebral haemorrhage and also severe gall-stone colic.
The disease has occasionalh' followed the infectious fevers. Cases have
been recorded as occurring during or immediately after diphtheria, influenza,
rheumatism, enteric fever, and syphilis.
Experimental Diabetes. — Leo believes that diabetes is due to a toxic agent.
He has produced glycosuria in dogs b}^ administering both fresh and fer-
mented diabetic urine. In 1901, Blum reported that the subcutaneous injec-
tion of an aqueous solution of adrenalin produced glycosuria in 22 out of 25
animals experimented upon. Herter confirmed these results, and found that
the direct application of the solution to the surface of the pancreas caused a
marked glycosuria. Adrenalin is a powerful reducing substance, and Herter
DIABETES MELLITUS. 411
thinks that the glycosuria results from interference with normal oxidation
processes in the pancreatic cells. Phloridzin administered internally or hypo-
dermically produces a marked temporary glycosuria. There is no accom-
panying hyperglycsemia. The phloridzin acts primarily on the renal epi-
thelium, destroying its power of keeping back the sugar. Naunyn and Klem-
perer hold the view that there is a renal form of diabetes.
Metabolism in Diabetes. — Our ignorance of the metabolic disturbances in
diabetes has been largely due to the fact that we have not known how the
carbohydrates are eventually disposed of in the body in health. Normally the
carbohydrates of the food are stored in the liver and muscles as glycogen.
Pavy holds that a part of the ingested carbohydrates is converted by the villi
of the intestinal mucosa into fat and carried thence by the lacteals to the
blood. By a splitting-off process another portion is incorporated with nitroge-
nous matters and carried away in the form of proteid. He thinks that only
a portion of the carbohydrates reaches the liver as glucose, where the hepatic
cells convert this monosaccharid into the polysaccharid glycogen. Glycogen
can also be formed from the proteids of the food; and under certain circum-
stances sugar can be directly formed from the body proteids. In health the
amount of glucose in the circulating blood ranges between 0.1 and 0.2 per
cent. If it were not for the reservoir action of the liver and muscles in storing
up the excess of carbohydrates after a meal as glycogen, we would have
more than 0.2 per cent of glucose in the blood, a hyperglycemia would occur
and a glycosuria ensue. In health the glycogen is reconverted into glucose,
which is distributed to the muscles by the circulating blood and there burnt
up, producing heat and energy.
The manner in which this final combustion is effected has hitherto not
been known. Cohnheim^s (Jr.) published researches in 1903 and 1904
throw much light on this subject. By a specially constructed press he
obtained the juice from the pancreas and muscles of dogs and cats. Each
Juice added independently to solutions of glucose was inert. When, however,
the pancreatic juice was added to a mixture of muscle juice and glucose there
was a rapid breaking up of the latter into alcohol and carbonic acid. Cohn-
heim holds that this remarkable effect is analogous to Pavlow's observation
that trypsinogen is only made active for proteid digestion by being converted
into trypsin by the " enterokinase " of the succus entericus. He believes that
the muscles produce a proenzyme which is only made active for carbohydrate
combustion by the action of another substance produced in the pancreas and
conveyed to the muscles by the blood stream. He showed that the glycolytic
substance produced by the pancreas is not a true ferment but a body closely
related in its characteristics with other well-known constituents of internal
secretions as adrenalin and iodothyrin. He also found that when too large
a quantity of the juice of the pancreas is used carbohydrate combustion is
retarded or even stopped. The pancreas juice is supposed to supply the am-
boceptors and the muscle juice the complement. The retarding action of an
excess of pancreas juice is believed to be due to an overabundance of ambo-
ceptors. According to these researches the carbohydrates normally are burnt
up in the muscles, producing heat and energy, by the combined action of two
glycolytic bodies, one produced in the muscles and the other in the pancreas.
This important work awaits confirmation.
412 CONSTITUTIONAL DISEASES.
Wlien the percentage of glucose in the circulating blood exceeds 0.3 per
cent a glycosuria occurs. This may theoretically be produced as follows :
(a) By functional or organic disease of the islands of Langerhans in the
pancreas. These islands of cells probably produce a glycol}rtic ferment or
body. This substance seems necessary for the proper burning up of the car-
bohydrates. If the islands be diseased the ferment is not produced, glucose
accumulates in the blood, and glycosuria results. This substance may act on
the carbohydrates independently, or, as Cohnheim believes, is necessary to
render active a pro-ferment manufactured by the muscle cells,
(&) By the sudden ingestion of a greater quantity of carbohydrates than
can for the time being be stored up in the liver as glycogen. A healthy per-
son can take from 180 to 250 grams of glucose on an empty stomach without
glycosuria occurring. Larger amounts will produce a so-called alimentary
glycosuria, or glycosuria e saccharo. In a healthy person no amount of
carbohydrates in the form of starch will produce a glycosuria owing to the
comparative slowness of its transformation into glucose. If, however, the
person's " assimilation limit," or power of warehousing carbohydrates, be
lowered, a glycosuria e am3io may occur.
(c) By changes in the liver function: (1) Changes in the circulation
under nervous influences. Puncture of the medulla, lesions of the cord, and
central irritation of various kinds are followed by glycosuria, which is
attributed to a vasomotor paralysis induced by these causes, resulting in a
greater quantity of blood flowing through the liver. On this view the disease
is a neurosis. (2) Instability of the glycogen, owing either to imperfect
formation or to conditions in the cells which render it less stable.
Morbid Anatomy. — Saundby (Lectures on Diabetes, 1891) has given a
good summary of the anatomical changes :
The nervous system shows no constant lesions. In a few instances there
have been tumors or sclerosis in the medulla, or, as in the case above men-
tioned, a cysticercus has pressed on the floor. Cysts have been met with in
the white matter of the cerebrum and perivascular changes have been de-
scribed. A secondary multiple neuritis is not rare, and to it the so-called
diabetic tabes is probably due. E. T. Williamson has found changes in the
posterior columns of the cord similar to those which occur in pernicious
anaemia.
In the sjTupathetic system the ganglia have been enlarged and in some
instances sclerosed. The hlood may contain as high as 0.4 per cent of sugar
Instead of 0.15 per cent. The plasma is usually loaded with fat, the mole-
cules of which may be seen as fine particles. When drawn, a white creamy
layer coats the coagulum, and there may be lipasmic clots in the small vessels.
There are no special changes in the red or white corpuscles. The polynuclear
leucocytes contain glycogen. Glycogen can occur in normal blood, but it is
here extracellular. It has been also found in the poljTiuclear leucocytes in
leukaemia. The heart is hypertrophied in some cases. Endocarditis is very
rare. Arterio-sclerosis is common. The lungs show important changes.
Acute broncho-pneumonia or croupous pneumonia (either of which may ter-
minate in gangrene) and tuberculosis are common. The so-called diabetic
phthisis is always tuberculous and results from a caseating broncho-pneu-
monia. In rare cases there is a chronic interstitial pneumonia, non-tubercu-
DIABETES MELLITUS. 413
lous. Fat embolism of the pulmonary vessels has been described in connection
with diabetic coma.
The liver is usually enlarged; fatty degeneration is common. In the so-
called diabetic cirrhosis — the cirrhose pigmentaire — the liver is enlarged and
sclerotic, and a cachexia develops with melanoderma. This condition is prob-
ably identical with hsemochromatosis. Dilatation of the stomach is common.
The Pancreas in Diabetes. — Our scientific knowledge of the relationship
of the pancreas to glycosuria dates from 1889, when Minkowski and von
Mering published the results of their experiments on extirpation of the pan-
creas in animals. The present status may be thus summarized: (a) Extir-
pation of the gland in dogs (and occasionally in man — W. T. Bull) is
followed by glycosuria. If a small portion remains, sugar does not appear.
(&) In a considerable percentage of cases of diabetes lesions of the pan-
creas are found; 50 per cent (Hansemann, Williamson) show a chronic
interstitial inflammation, (c) In view of the experimental work, it is
reasonable to infer that the diabetes is secondary to the pancreatic lesion.
The organ has, like the liver, a double secretion — an external, which is
poured into the intestines, and an internal, of the nature either of a ferment
or of a body similar in chemical characteristics to those of adrenalin or
iodothyrin, as Cohnheim claims, which seems necessary for the proper com-
bustion of glucose in the muscles. Disease of the pancreas causes diabetes
by preventing the formation of this glycolytic body. The fact that if a
small portion of the gland is left, in the experiments upon dogs, diabetes
does not occur, is analogous to the remarkable circumstance that a small
fragment of the thyroid is sufficient to prevent the occurrence of artificial
myxoedema.
It is probable that the observations of Opie from Dr. Welch's laboratory,
confirmed by those of Weichselbaum and Stange, give a key to the problem.
Imbedded in the gland are the peculiar bodies known as the islands of Lan-
gerhans, composed of polygonal cells arranged in irregular columns, between
which are wide anastomosing capillaries. The lumina of the ducts do not
enter the islands, which are in reality ductless glands, like the para-thyroid,
the thyroid, the pituitary; etc. The intimate relation of the columns of cells
to the rich network of blood-vessels suggests, as advanced by Schafer, that
they furnish the internal secretion of the gland. It is probable that the glyco-
l3rtic body found by Cohnheim is produced by these specialized cells.. Ex-
perimental evidence is defective, but changes in the islands have been found
in diabetes. In a diabetic woman, aged twenty-four, from my wards, dead
of tuberculosis of the lungs, Opie found the glandular tissue of the pancreas
well preserved and healthy, but the islands of Langerhans were everywhere
" represented by a sharply circumscribed hyaline structure composed of par-
ticles of homogeneous material." In two other cases lesions of the islands
were found, but there was also chronic pancreatitis (Opie, Jour. Exper. Med.,
vol. v). Hoppe-Seyler has recently described a clinical form of pancreatic
diabetes due to arterio-sclerosis of the pancreatic vessels. These arterial
changes were found in a series of autopsies.
Of 15 autopsies from my own 27 cases, in 9 on gross examination the
pancreas was found to be atrophic. In one of these fat necroses, and in
another calculi, were present.
414 CONSTITUTIONAL DISEASES.
The kidneys show usually a diffuse nephritis with fatty degeneration. A
hyaline change occurs in the tubal epithelium, particularly of the descending
limb of the loop of Henle, and also in the capillary vessels of the tufts.
Symptoms. — Acute and chronic forms are recognized, but there is no
essential difference between them, except that in the former the patients are
younger, the course is more rapid, and the emaciation more marked. Acute
eases may occur in the aged. I saw with Sowers in Washington a man aged
seventy-three in whom the entire course of the disease was less than three
weeks.
It is also possible to divide the cases into (1) lipogenic or dietetic, which
includes the transient glycosuria of stout persons; (2) neurotic, due to in-
juries or functional disorders of the nervous system; and (3) pancreatic,
in which there is a lesion of the pancreas. It is, however, by no means easy
to discriminate in all cases between these forms. Attempts have been made
to separate a clinical variety analogous to experimental pancreatic diabetes.
Hirsehfeld, from Guttman's clinic^ has described cases running a rapid and
severe course usually in young and - middle-aged persons. The polyuria is
less common or even absent, and there is a striking defect in the assimilation
of the albuminoids and fats, as sho\^Ti by the examination of the fgeces and
urine. In 4 of 7 eases autopsies were made and the pancreas was found
atrophic in two, cancerous in one, and in the fourth exceedingly soft.
The onset of the disease is gradual, and either frequent micturition or
inordinate thirst first attracts attention. Very rarely it sets in rapidly, after
a sudden emotion, an injury, or after a severe chill. When fully established
the disease is characterized by great thirst, the passage of large quantities
of saccharine urine, a voracious appetite, and, as a rule, progressive ema-
ciation.
Among the general symptoms of the disease thirst is one of the most
distressing. Large quantities of water are required to keep the sugar in
solution and for its excretion in the urine. The amount of fluid consumed
will be found to bear a definite ratio to the quantity excreted. Instances,
however, are not uncommon of pronounced diabetes in which the thirst is
not excessive; but in such cases the amount of urine passed is never large.
The thirst is most intense an hour or two after meals. As a rule, the diges-
tion is good and the appetite inordinate. The condition is sometimes termed
'bulimia or polyphagia. Lumbar pain is common.
The tongue is usually dry, red, and glazed, and the saliva scanty. The
gums may become swollen, and in the later stages aphthous stomatitis is
common. Constipation is the rule.
In spite of the enormous amount of food consumed a patient may be-
come rapidly emaciated. This loss of flesh bears some ratio to the polyuria,
and when, under suitable diet, the sugar is reduced, the patient may quickly
gain in flesh. The skin is dry and harsh, and sweating rarely occurs, except
when phthisis coexists. Drenching sweats have been known to alternate
with excessive polyuria. General pruritus or pruritus pudendi may be very
distressing, and occasionally is one of the earliest symptoms. The tempera-
ture is often subnormal; the pulse is usually frequent, and the tension in-
creased. Many diabetics, however, do not show marked emaciation. Patients
past the middle period of life may have the disease for years without much
DIABETES MELLITUS. 415
disturbance of the healthy and may remain well nourished. These are the
cases of the diahete gras in contradistinction to diahete maigre.
The Ueine. — The amount varies from 3 to 4 litres in mild cases to
15 to 20 litres in very severe cases. In rare instances the quantity of urine
is not much increased. Under strict diet the amount is much lessened, and
in intercurrent febrile affections it may be reduced to normal. The specific
gravity is high, ranging from 1.025 to 1.045; but in exceptional cases it
may be low, 1.013 to 1.020. The highest specific gravity recorded, ^o far
as I know, is by Trousseau — 1.074. Very high specific gravities — 1.070 -|-
— suggest fraud. The urine is pale in color, almost like water, and has a
sweetish odor and a distinctly sweetish taste. The reaction is acid. Sugar
is present in varying amounts. In mild cases it does not exceed 1^ or 2 per
cent, but it may reach from 5 to 10 per cent. The total amount excreted in
the twenty-four hours may range from 10 to 20 ounces (320 to 640 grammes)
and in exceptional cases from 1 to 2 pounds. The following are the most
satisfactory tests:
Fehling's Test. — The solution consists of sulphate of copper (grs. 90^),
neutral tartrate of potassium (grs. 364), solution of caustic soda (fl. ozs. 4),
and distilled water to make up 6 ounces. Put a drachm of this in a test-
tube and boil (to test the reagent) ; add an equal quantity of urine and boil
again, when, if sugar is present, the yellow suboxide of copper is thrown
down. The solution must be freshly prepared, as it is apt to decompose.
Trommer's Test. — To a drachm of urine in a test-tube add a few drops
of a dilute sulphate-of-copper solution and then as much liquor potasscB as
urine. On boiling, the copper is reduced if sugar be present, forming the
yellow or orange-red suboxide. There are certain fallacies in the copper
tests. Thus, a substance called glycuronic acid is met with in the urine
after the use of certain drugs — chloral, phenacetin, morphia, chloroform,
etc. — which reduces copper. Alcaptonuria may also be a source of error
(see Alcaptonuria).
Fermentation Test. — This is free from all doubt. Place a small frag-
ment of yeast in a test-tube full of urine, which is then inverted over a glass
vessel containing the same fluid. There are now specially devised fermenta-
tion tubes. If sugar is present, fermentation goes on with the formation
of carbon dioxide, which accumulates in the upper part of the tube and
gradually expels the urine. In doubtful cases a control test should always
be used.
Folariscope Test. — For laboratory work the polariscope test is of great
value. Glucose is dextro-rotatory. The percentage of sugar can be quickly
estimated by the degree of rotation, and for quantitative determination is
the most serviceable method. The presence of )8-oxybutyric acid, which is
Isevo-rotatory, will neutralize some of the dextro-rotatory action of the glucose.
Nylanders Bismuth Test. — Nylander's solution is prepared by dissolving
4 grammes of Eochelle salt in 100 cc. of 10 per cent caustic soda solution and
adding 2 grammes of bismuth subnitrate and digesting on the water-bath until
as much of the bismuth salt is dissolved as possible. To 10 cc. of urine add
1 cc. of the Nylander's solution and boil for a few minutes. If glucose be
present a black deposit of bismuth occurs.
Of other ingredients in the urine, the urea is increased, the uric acid
416 CONSTITUTIONAL DISEASES.
does not show special changes, and the phosphates may be greatly in excess.
The calcium salts are markedly increased. The same holds true for the
ammonia in all severe cases, and particularly in diabetic coma. Ralfe has
described a great increase in the phosphates, and in some of these cases,
with an excessive excretion, the symptoms may be very similar to those of
diabetes, though the sugar may not be constantly present. The term phos-
phatic diabetes has sometimes been applied to them. Acetone and acetone-
forming substances are not infrequently present. Lieben's test is as follows :
The urine is distilled and a few cubic centimetres of the distillate are ren-
dered alkaline with liquor potassae. A few drops of Lugol's solution are
then added, when, if acetone be present, the distillate assumes a turbid yellow
color, due to the formation of iodoform, which is recognized by its odor and
by the formation of minute hexagonal and stellate crystals, Diacetic acid-
is sometimes present, and may be recognized from the fact that a solution
of the chloride of iron yields a beautiful Bordeaux-red color. Other sub-
stances, as formic, carbolic, and salicylic acids, give the same reaction in
both fresh and previously boiled urine, while diacetic acid does not give
the reaction in urine previously boiled. In testing for diacetic acid perfectly
fresh urine should be used, as it rapidly becomes broken up into acetone and
carbonic acid, ^-oxybutyric acid, the recognized cause of coma, should be
tested for in all severe cases. As it is lasvo-rotatory, its presence is indicated
by Isevo-rotation in completely fermented urine, as well as by the greater
percentage of sugar demonstrable with Fehling's than with the polariscopic
method. The occurrence of acetone and diacetic acid in the urine, both
derivative products of /8-ox3^butyric acid, is conclusive evidence that yS'-oxy-
butyrie acid is being produced in the body.
Bremer finds that diabetic urine has the power of dissolving gentian violet,
whereas normal urine fails to do so. Unfortunately, the urine in diabetes
insipidus and in certain forms of polyuria reacts similarly. Frohlich has
recently devised a test based on the fact that diabetic urine has the property
of decolorizing solutions of methylene blue.
Glycogen has also been described as present in the urine.
Albumin is not infrequent. It occurred in nearly 37 per cent of the
examinations made by Lippman at Carlsbad.
Pneumaturia, the formation of gas in the urine, due to fermentative
processes in the bladder, is occcasionally met with.
Gammidge found glycerine in the urine in one case of pancreatic diabetes.
This results from fat necroses due to the action of a fat-splitting ferment.
Fat may be passed in the urine in the form of a fine emulsion (lipuria).
Blood in Diabetes. — In true diabetes hyperglycsemia is constant. As
coma supervenes, y8-oxybutyric acid occurs. Polycythsemia, with the red
cells between 6,000,000 and 8,000,000 per cmm., is not uncommon in the
desiccated cases with marked polyuria. Coma is accompanied by a moderate
leucocytosis. Lipgemia occurs in a certain number of cases. It is recognized
by the presence of innumerable dancing particles between the red cells in a
fresh preparation, and by the creamy appearance of the serum of centrif-
ugalized blood. Normal blood contains between 0.16 to 0.325 per cent of
fat (Becquerel and Eodier). Fraser found 16.44 per cent of fat in the blood
of a diabetic. Opinions vary as to the source of the fat.
DIABETES MELLITUS. 417
Diabetes in Children. — Stern has analyzed 117 cases in children. They
usually occur among the better classes. Six were under one year of age.
Hereditary influences were marked. The course of the disease is, as a rule,
much more rapid than in adults. The shortest duration was two days. In
7 cases it did not last a month. One case is mentioned of a child apparently
born with the glycosuria, who recovered in eight months.
Complications. — (a) Cutaneous. — Boils and carbuncles are extremely
common. Painful onychia may occur. Eczema is also met with, and at
times an intolerable itching. In women the irritation of the urine may cause
the most intense pruritus pudendi, and in men a balanitis. Earer affections
are xanthoma and purpura. Gangrene is not uncommon, and is associated
usually with arterio-sclerosis. William Hunt has analyzed 64 cases. In 50
the localities were as follows: Feet and legs, 37; thigh and buttock, 2; nucha,
2 ; external genitals, 1 ; lungs, 3 ; fingers, 3 ; back, 1 ; eyes, 1. Perforating
ulcer of the foot may occur. Bronzing of the skin (diaiete bronze) occurs
in certain cases in which the diabetes arises as a late event in the disease
known as htemochromatosis, which is further characterized by pigmentary
cirrhosis of the liver and pancreas. With the onset of severe complications
the tolerance of the carbohydrates is much increased. Profuse sweats may
occur.
(&) Pulmonary. — The patients are not infrequently carried off by aade
pneumonia^ which may be lobar or lobular. Gangrene is very apt to super-
vene, but the breath does not necessarily have the foul odor of ordinary
gangrene. Abscess following lobar pneumonia occurred in one of my cases.
Tuberculous hronclio- pneumonia is very common. It was formerly thought,
from its rapid course and the limitation of the disease to the lung, that this
was not a true tuberculous affection ; but in the cases which have come under
my notice the bacilli have been present, and the condition is now generally
regarded as tuberculous.
(c) Renal. — Albuminuria is a tolerably frequent complication. The
amount varies greatly, and, when slight, does not seem to be of much mo-
ment. CEdema of the feet and ankles is not an infrequent symptom. ,Greneral
anasarca is rare, however, owing to the marked polyuria. It is sometimes
associated with arterio-sclerosis. It occasionally precedes the occurrence of
the diabetic coma. Occasionally cystitis develops.
(d) Nervous System. — (1) Diabetic coma, first studied by Kussmaul,
comes on in a considerable proportion of all cases, particularly in the young.
Stephen Mackenzie states that of the fatal cases of diabetes at tilie London
Hospital, all under the age of twenty-five, with but one exception, had died
in coma. In Naunyn's 44 fatal cases it occurred in 12. It preceded death
in 28 of Williamson's 40 cases. It occurred in 15 of 27 fatal cases in my
series. Frerichs recognized three groups of cases: (a) Those in which after
exertion the patients were suddenly attacked with weakness, syncope, som-
nolence, and gradually deepening unconsciousness; death occurring in a few
hours, (ft) Cases with preliminary gastric disturbance, such as nausea and
vomiting, or some local affection, as pharyngitis, phlegmon, or a pulmonary
complication. In such cases the attack begins with headache, delirium, great
distress, and dyspnoea, affecting both inspiration and expiration, a condition
called by Kussmaul air-hunger. Cyanosis may or may not be present. If it
418 CONSTITUTIONAL DISEASES.
is, the pulse becomes rapid and weak and the patient gradually sinks into
coma; the attack lasting from one to five days. There may be a very heavy
sweetish odor of the breath, due to the presence of acetone, (y) Cases in
which, without an,y previous dyspncea or distress, the patient is attacked with
headache and a feeling of intoxication, and rapidly falls into a deep and
fatal coma. There are atypical cases in which the coma is due to uraemia,
to apoplexy, or to meningitis.
There has been much dispute as to the nature of these symptoms, but
clinical laboratory investigations have practically afforded a satisfactory ex-
planation. For years the coma symptoms were ascribed to the toxic effects
of acetone and later to those of diacetic acid. Experimental work, however,
showed that these views were incorrect. The almost universal opinion now
is that the coma is due to an acid intoxication, or, as Naunyn terms it, an
acidosis. The ofEending agent is believed to be y8-oxybutyric acid, which
accumulates in the tissues and circulating blood in enormous quantities, and
is eliminated in the urine in combination with various base-forming elements,
but never free. In 1884 Stadelmann, Kiilz, and Minkowski almost simul-
taneously found this acid in the urine of patients with diabetic coma. Sub-
sequent researches, particularly those published from Naunyn's clinic, have
fully confirmed these results, and it is now almost universally accepted that
^-oxybutyric acid is the cause of diabetic coma. The amount of the acid
excreted in the twenty-four hours may be enormous. Kiilz found in 3 cases
67, 100, and 226 grammes respectively. Magnus-Levy has estimated that
from 100 to 200 grammes are often contained in the tissues of fatal cases.
This author is of the belief that the ^-oxybutyric acid is derived from the
fats of the body, whereas most observers, including Naunyn, trace it to the
disintegration of the tissue albumins. Acetone and diacetic acid are deriva-
tive products of the j8-oxybut}Tic acid.
Saunders and Hamilton have described cases in which the lung capillaries
were blocked with fat. They attributed the symptoms to fat embolism, but
there are many cases on record in which this condition was not found, though
lipgemia is by no means infrequent in diabetes.
Albuminuria frequently precedes or accompanies the attack, and numer-
ous small, short, hyaline, and finely granular casts are demonstrable.
(2) Peripheral Neuritis. — The neuralgias^ numbness, and tingling, which
are not uncommon symptoms in diabetes, are probably minor neuritic mani-
festations. The involvement may be general of the upper and lower extrem-
ities. Sometimes it is unilateral, or the neuritis may be in a single nerve —
the sciatic or the third nerve. Herpes zoster may occur. Perforating ulcer
of the foot may develop.
Diabetic Tabes (so-called). — This is a peripheral neuritis, characterized
by lightning pains in the legs, loss of knee-jerk — which may occur without
the other symptoms — and a loss of power in the extensors of the feet. The
gait is the characteristic steppage, as in arsenical, alcoholic, and other forms
of neuritic paralysis. Charcot states that there may be atrophy of the optic
nerves. Changes in the posterior columns of the cord have been found by
Williamson and others.
Diabetic Paraplegia. — This is also in all probability due to neuritis.
There are cases in which power has been lost in both arms and legs.
DIABETES MELLITUS. 419
(3) Mental Symptoms. — The patients are often morose, and there is a
strong tendency to become hypochondriacal. General paralysis has been met
with. Some patients display an extraordinary degree of restlessness and
anxiety.
(4) Special Senses. — Cataract is liable to occur, and with rapidity in
young persons. Diabetic retinitis closely resembles the albuminuric form.
Haemorrhages are common. Sudden amaurosis, similar to that which occurs
in uraemia, may occur. Paralysis of the muscles of accommodation may be
present; and lastly, atrophy of the optic nerves. Aural symptoms may come
on with great rapidity, either an otitis media, or in some instances inflamma-
tion of the mastoid cells.
(5) Sexual Function. — Impotence is common, and may be an early symp-
tom. Conception is rare; if it occurs, abortion is apt to follow. A diabetic
mother may bear a healthy child ; there is no known instance of a dia-
betic mother bearing a diabetic child. The course of the disease is usually
aggravated after delivery.
Course. — In children the disease is rapidly progressive, and may prove
fatal in a few days. In young persons death almost invariably results from
diabetic coma. It may be stated, as a general rule, that the" older the patient
at the time of onset the slower the course. Cases without hereditary influ-
ences are the most favorable. In stout, elderly men diabetes is a much more
hopeful disease than it is in thin persons. Middle-aged patients may live for
many years, and persons are met with who have had the disease for ten,
twelve, or even fifteen years.
Diagnosis. — As stated in the definition, for a case to be considered diabetes
the sugar eliminated in the urine must be grape sugar, it should be present
for weeks, months, or years, and the excretion of sugar must take place after
the ingestion of moderate amounts of carbohydrates. Alimentary or dietetic
glycosuria must not be confused with true diabetes. As a rule, there is no
difficulty in determining the presence of diabetes. The diagnosis must be
made chiefly by the urine tests already given. More than one test must be
used, and where there is any doubt the fermentation test, the most reliable
single test, must be made. One must always exclude the possibility of the
copper sulphate reduction being due to glycuronic acid compounds and to
homogentisic acid, the latter the cause of alcaptonuria. Bremer showed that
the red cells in diabetic blood fail to take the red stain as normal reds do.
The test may be of some service when a patient is first seen in coma, which
may be thought to be diabetic, and where urine is not at once available.
Williamson found that diabetic blood possesses the power of decolorizing
weak alkaline solutions of methylene blue to a yellowish-green or yellow
color.
Occasionally intermittent glycosuria occurs. It is advisable in these cases
to determine the assimilation limit for carbohydrates. According to Kaunyn,
100 grammes of glucose given in solution two hours after a breakfast of a
roll and butter with coffee ought not to cause a glycosuria. If it does, the
individual's power of warehousing carbohydrates is lowei'ed and a permanent
glycosuria — ^true diabetes — may eventually ensue.
Deception may be practised. A young girl under my care had urine with
a specific gravity of 1.065, The reactions were for cane sugar. There is one
420 CONSTITUTIONAL DISEASES.
case in the literature in which, after the cane-sugar fraud was detected, the
woman bought grape sugar and put it into her bladder !
Prognosis. — In true diabetes instances of cure are rare. On the other
hand, the transient or intermittent glycosuria, met with in stout overfeeders,
or in persons who have undergone a severe mental strain, is very amenable
to treatment. Not a few of the cases of reputed cures belong to this division.
Practically, in cases under forty years of age the outlook is bad; in older
persons the disease is less serious and much more amenable to treatment. It
is a good plan at the outset to determine whether the urine of a patient con-
tains sugar or not on a diet absolutely free from carbohydrates. If the sugar
disappears the case may be regarded as a mild one. If, on the other hand,
sugar continues to be excreted, it is a severe one, and the patient is manu-
facturing sugar from his body proteids. The presence of ^-oxybutyric or
diacetic acids in the urine is usually of serious import, and should warn the
physician of the possible occurrence of coma. Occasionally diacetic acid may
be present for months, apparently without serious consequences.
Treatment. — In families with a marked predisposition to the disease the
use of starchy and saccharine articles of diet should be restricted.
The personal hygiene of a diabetic patient is of the first importance.
Sources of worry should be avoided, and he should lead an even, quiet life,,
if possible in an equable climate. Flannel or silk should be worn next to
the skin, and the greatest care should be taken to promote its action. A
lukewarm, or, if tolerably robust, a cold bath, should be taken every day. An
occasional Turkish bath is useful. Systematic, moderate exercise should be
taken. When this is not feasible, massage should be given. It is well to
study accurately the dietetic capabilities of each case. No two cases can be
treated alike. The weight should be recorded weekly. A patient who is
glycosuric and losing weight on a non-carbohydrate diet must be regarded
as doing badly. By the addition of a certain amount of starchy food the
same person may excrete a moderate amount of sugar and hold or even gain
in weight.
Diet. — Our injunctions to-day are those of Sydenham : " Let the patient
eat food of easy digestion, such as veal, mutton, and the like, and abstain
from all sorts of fruit and garden stuff."
When a diabetic patient, in private or hospital practice, comes under treat-
ment, it is well to keep him for three or four days on the ordinary diet, which
contains moderate amounts of carbohydrates, in order to ascertain the amount
of sugar excretion. For two days more the starches are gradually cut off.
He is then placed on the following non-carbohydrate diet, modified in each
case according to the patient's age and weight, and arranged from a list
recommended by von Noorden:
Breakfast: 7.30, 200 cc. (o^i) of tea or coffee: 150 grammes (§iv) of
beefsteak, mutton-chops without bone, or boiled ham ; one or two eggs.
Lunch: 12.30, 200 grammes (§vi) cold roast beef; 60 grammes (^ij)
celery, fresh cucumbers or tomatoes with vinegar, olive oil, pepper and salt
to taste; 20 cc. (5v) whisky with 400 cc. (o^iij) water; 60 cc. (oij) coffee,
without milk or sugar.
Dinner: 6 p.m., 200 cc. clear bouillon; 250 grammes (§ viiss) roast beef;
10 grammes' (.Diiss) butter; 80 grammes (oij) green salad, with 10 grammes
DIABETES MELLITUS. 421
(Siiss) vinegar and 20 grammes (ov) olive oil, or three tablespoonfuls of
some well-cooked green vegetable; three sardines a I'huile; 20 cc. (3 v) whisky,
with 400 cc. (gxiij) water.
Supper: 9 p. m., two eggs (raw or cooked) ; 400 cc. (§xiij) water.
This diet contains about 200 grammes of albumin and about 135 gramtnes
of fat. The effect of the diet on the sugar excretion is remarkable. In many
cases there is an entire disappearance of the sugar from the urine in three
or four days. Chart XV shows very graphically the remarkable drop in the
sugar excretion for the first twenty-four hours. In cases in which the urine
becomes free from sugar, gradually increasing quantities of starch up to 20,
50, and 100 grammes are added daily. White bread contains fifty- five per
cent of starch. The efl'ect of the non-carbohydrate diet, according to von
Noorden, is to improve the metabolic functions so that the system can ware-
house considerable quantities of carbohydrates without sugar appearing in the
urine. Naunyn emphasizes the importance of removing the hyperglycsemia
and making the patient aglycosuric. In patients on a strict diet who con-
tinue to excrete from 0.1 to 0.5 per cent of glucose, he advises a " hunger-day,"
during which all food is cut off for twenty-four hours. In many such instances
aglycosuria occurs, and the patient's power of assimilating carbohydrates is
thought to be increased.
In cases in which a standard diet is not ordered it is well to begin cutting
off article by article until the sugar disappears from the urine. Within a
month or two the patient may be allowed a more liberal diet, testing the
different kinds of food.
The oatmeal diet, introduced by von Noorden, is most excellent, particularly
in the severer forms. Two hundred and fifty grammes of oatmeal, the same
amount of butter and the whites of six or eight eggs constitute the day's food.
The oatmeal is cooked for two hours, and the butter and albumin stirred
in. It may be taken in four portions during the day. Coffee, tea, or whisky
and water may be taken with it.
The following is a list of articles which diabetic patients may take :
Liquids: Soups — ox-tail, turtle, bouillon, and other clear soups. Lemon-
ade, coffee, tea, chocolate, and cocoa ; these to be taken without sugar, but
they may be sweetened with saccharin. Potash or soda water, and Apol-
linaris, or the Saratoga- Vichy, and milk in moderation, may be used.
Of animal food: Fish of all sorts, including crabs, lobsters, and oysters;
salt and fresh butcher's meat (with the exception of liver), poultry, and
game. Eggs, butter, buttermilk, curds, and cream cheese.
Of bread: Gluten and bran bread, and almond and cocoanut biscuits.
Aleuronat and roborat fiours are made from wheat and contain large quan-
tities of albumin and but little starch. They may be used in making bread
or biscuits, and are highly recommended by Ebstein.
Of vegetables : Lettuce, tomatoes, spinach, chicory, sorrel, radishes, aspara-
gus, water-cress, cucumbers, celery, endives, mustard and various pickles.
Fruits: Lemons and oranges. Currants, plums, cherries, pears, apples
(tart), melons, raspberries, and strawberries may be taken in moderation.
Nuts are, as a rule, allowable.
Among prohibited articles are the following : Thick soups and liver.
Ordinary bread of all sorts (in quantity), rye, wheaten, brown, or white.
422
CONSTITUTIONAL DISEASES.
All farinaceous preparations, sucli as hominv, rice, tapioca, semolina, arrow-
root, sago, and vermicelli.
Of vegetables : Potatoes, turnips, parsnips, squashes, vegetable-marrows
of all kinds, beets, corn, artichokes.
Of liquids : Beer, sparkling wine of all sorts, and the sweet aerated
drinks.
In feeding a diabetic patient one of the greatest difficulties is in arranging
a substitute for bread. Of the gluten foods, many are very unpalatable;
others are frauds.
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Chart XY. — Illustrating Ixfluexce of Diet ox Sugar axb Amouxt of Urixe.
Other substitutes are the almond food, the Aleuronat bread, and soya
bread, but these and other substitutes are not satisfactory as a rule. For
sweetening purposes saccharin may be used, of which tablets are prepared.
Mosse has shown that potato starch is more easily assimilated than wheat
starch, and this view has been on the whole confirmed by comparative tests
in my wards. He allows as much as a kilo (2^ pounds) of potatoes, weighed
fresh, to a diabetic dailv. Thev are best baked.
DIABETES MELLITUS. 423
Medicinal Treatment. — This is most unsatisfactory, and no one drug
appears to have a directly curative influence. Opium alone stands the test
of experience as a remedy capable of limiting the progress of the disease.
Diabetic patients seem to have a special tolerance for this drug. Codeia is
preferred by Pavy, and has the advantage of being less constipating than
morphia, A patient may begin with half a grain three times a day, which
may be gradually increased to 6 or 8 grains in the twenty-four hours. Not
much effect is noticed unless the patient is on a rigid diet. When the Sugar
is reduced to a minimum, or is absent, the opium should be gradually with-
drawn. The patients not only bear well these large doses of the drug, but
they stand its gradual reduction. Potassium bromide is often a useful
adjunct. The arsenite of bromine, a solution of arsenious acid with bromine
in glycerin (dose, 3 to 5 minims after meals), has been very highly recom-
mended, but it is by no means so certain as opium. Arsenic alone may be
used. Antipyrin may be given in doses of 10 grains three times a day, and
in cases with a marked neurotic constitution is sometimes satisfactory. The
salicylates, iodoform, nitroglycerin, jambul, the lithium salts, strychnine,
creasote, and lactic acid have been employed.
Preparations of the pancreas (glj^cerin extracts of the dried and fresh
gland) have been used in the hope that they would supply the internal secre-
tion necessary to normal sugar metabolism. The success has not, however,
been in any way comparable with that obtained with the thyroid extract in
myxoedema. Lepine has isolated a glycolytic ferment from the pancreas and
also from the malt diastase, and has used it with some success in 4 cases.
As yet no practical therapeutic results have . followed Cohnheim's obser-
vations.
Of the complications, the pruritus and eczema are best treated by cooling
lotions of boric acid or hyposulphite of soda (1 ounce; water, 1 quart), or
the use of ichthyol and lanolin ointment.
In the thin, nervous cases the bowels should be kept open and the urine
tested at short intervals for acetone and diacetic acid — the derivatives of
^-oxybutyric acid.
The coma is an almost hopeless complication. Inhalations of oxygen have
been recommended. The use of bicarbonate of soda in very large doses is
recommended to neutralize the acid intoxication. It may be used intra-
venously; as much as 80 grammes have been injected. The solution used
for intravenous injection is a 1 to 2 per cent solution of sodium bicarbonate
in normal salt solution. A litre may be injected slowly into a vein every six
hours in desperate cases. In the less serious cases administration should be
made by mouth, or mouth and rectum. This treatment was first recom-
mended by Stadelmann, and has undoubtedly given the best results. Naun}Ti
and Magnus-Levy report cases of recovery from coma by its use. I have had
one recovery. The sodium bicarbonate should be pushed until the urine is
alkaline. As much as 100 grammes should be given daily. All diabetics with
a marked diacetic acid reaction in the urine should be placed on sodium
bicarbonate. JSText to the antacid treatment, subcutaneous or intravenous
injections of normal salt solution have given the best results. The im-
provement, unfortunately, is only temporary with this line of treatment.
Eeynolds published 2 eases of recovery after the administration of a dose of
424 CONSTITUTIONAL DISEASES.
castor oil, followed by 30 to 60 grains of citrate of potassium every hour in
copious draughts of water. The bowels of a diabetic patient should be kept
acting freely, as constipation is believed to predispose to the development
of coma.
VI. DIABETES INSIPIDUS.
Definition. — A chronic affection characterized by the passage of large
quantities of normal urine of low specific gravity.
The condition is to be distinguished from diuresis or pohniria, which is
a frequent s}"mptom in hysteria, in Bright's disease, and occasionally in cere-
bral or other affections. Willis, in 1674, first recognized the distinction
between a saccharine and non-saccharine form of diabetes.
Etiology. — The disease is most common in young persons. Of the 85
cases collected by Strauss, 9 were under five years; 12 between five and ten
years; 36 between ten and twent^^-five years. Males are more frequently
attacked than females. The affection may be congenital. A hereditary
tendency has been noted in many instances, the most extraordinary of which
has been reported by Weil. Of 91 members in four generations, 23 had
persistent polyuria without any deterioration in health.
CLiifiCAL Classificatiox. — There are two forms : primary or idiopathic,
in which there is no evident organic basis, and secondary or S}Tnptomatic, in
which there is evidence of disease in the brain or elsewhere. Of 9 cases re-
ported from my clinic by Futcher, 4 belonged to the former and 5 to the
latter group. Trousseau stated that the parents of children vdth diabetes
insipidus frequently have glycosuria or albuminuria. Ealfe claimed that mal-
nutrition is an important predisposing factor in children. The disease has
followed rapidly the copious drinking of cold water, or a drinking bout, or
has set in during the convalescence from an acute disease.
The secondary or symptomatic form is almost always associated with in-
jury or disease of the nervous system, traumatism to the head, or, in some
cases, to the trunk. It occurs in 30 per cent of the cases, according to Stoer-
mer. Tumors of the brain, lesions of the medulla, cerebral hemorrhage, have
been met with in some cases. There is a remarkable association between
diabetes insipidus and brain s}'philis; 5 of the 9 cases reported by Futcher
were in syphilitics. The lesion is usualh" at the base, and meningitic. Hemi-
anopsia is present in a number of these cases; it occurred in 2 of Futcher's
series. It is not necessary that the lesion should involve the medulla. It has
been met with in spinal cord lesions. In tumors and aneurisms in the abdo-
men, in tuberculous jjeritonitis, and in carcinoma there may be polyuria of
an extreme grade.
The most reasonable view of the production of the polyuria is that it
results from a vaso-motor disturbance of the renal vessels, due either to local
irritation, as in a case of abdominal tumor, to central disturbance in cases
of brain-lesion, or to functional irritation of the centre in the medulla, giving
rise to continuous renal congestion.
Morbid Anatomy. — There are no constant anatomical lesions. The I'id-
neys have been found enlarged and congested. The bladder has been found
h^-pertrophied. Dilatation of the ureters and of the pelves of the kidneys has
DIABETES INSIPIDUS. 425
been present. Death has not infrequently resulted from chronic pulmonary-
disease. Very varied lesions have been met with in the nervous system.
Symptoms. — The disease may come on rapidly, as after a fright or an
injury; more commonly it is gradual. According to Ealfe, the patients often
complain in the early stages of severe racking pains in the lumbar region
shooting down the thighs. A copious secretion of urine, with increased thirst,
are the prominent features of the disease. The amount of urine in the twen-
ty-four hours may range from 20 to 40 pints, or even more. Trousseau speaks
of a patient who consumed 50 pints of fluid daily and passed about 56 pints
of urine in the twenty-four hours. In two of our cases, the amount passed
was greater than that ingested in liquids and solids. The specific gravity is
low, 1.001 to 1.005; the color is extremely pale and watery. The total solid
constituents may not be reduced. The amount of urea has sometimes been
found in excess. Abnormal ingredients are rare. Muscle-sugar, inosite, has
been occasionally found. Albumin is rare. Traces of sugar have been met
with. Naturally, with the passage of such enormous quantities of urine, there
is a proportionate thirst, and the only inconvenience of the disease is the
necessity for frequent micturition and frequent drinking. The appetite i^
usually good, rarely excessive as in diabetes mellitus; but Trousseau tells
of the terror inspired by one of his patients in the keepers of those eating-
houses where bread was allowed without extra charge to the extent of each
customer's wishes, and says that the man was paid to stay away. The patients
may be well nourished and healthy-looking. The disease in many instances
does not appear to interfere in any way with the general health. The per-
spiration is naturally slight and the skin is harsh. The amount of saliva is
small and the mouth usually dry. The tolerance of alcohol is remarkable,
and patients have been known to take a couple of pints of brandy, or a dozen
or more bottles of wine, in the day.
The course depends entirely upon the nature of the primary trouble.
Sometimes, with organic disease, either cerebral or abdominal, the general
health is much impaired ; the patient becomes thin, and rapidly loses strength.
In the essential or idiopathic cases, good health may be maintained for an
indefinite period, and the affection has been known to persist for fifty years.
Death usually results from some intercurrent affection. Spontaneous cure
may take place.
Dia^osis. — A low specific gravity and the absence of sugar in the urine
distinguish the disease from diabetes mellitus. Hysterical polyuria may
sometimes simulate it very closely. The amount of urine excreted may be
enormous, and only the development of other hysterical manifestations may
enable the diagnosis to be made. This condition is, however, always transi-
tory.
In certain cases of chronic Bright's disease a very large amount of urine
of low specific gravity may be passed, but the presence of albumin and of
hyaline casts, and the existence of heightened arterial tension, stiff vessels,
and hypertrophied left ventricle make the diagnosis easy.
Treatment. — The treatment is not satisfactory. No attempt should be
made to reduce the amount of liquid. Opium is highly recommended, but
is of doubtful service. The preparations of valerian may be tried ; either the
powdered root, beginning with 5 grains three times a day, and increasing
426 CONSTITUTIONAL DISEASES.
until 2 drachms are taken in the day, or the valerianate of zinc, in 15-grain
doses, gradually increased to 30 grains, three times a day. Anti-syphilitic
treatment should be thoroughly tried in those cases with a suspicious history.
Ergot, ergotin, antipyrin, the salicylates, arsenic, strychnine, turpentiae, and
the bromides ha^e been recommended. Electricity may be used.
VII. RICKETS (Rhachitis).
Definition. — A disease of infants, characterized by impaired nutrition of
the entire body and alterations in the growing bones.
Glisson, the anatomist of the liver, accurately described the disease in
1650. The name is derived from the old English word wriclcken, to twist,
Glisson suggested to change the name to rhachitis, from the Greek, pd.xi-%
the spine, as it was one of the first parts affected, and also from the similarity
in the sound to rickets.
Etiology. — Eickets exists in all parts of the world, but is particularly
marked among the poor of the larger cities, who are badly housed and ill fed.
It is much more common in Europe than in America. In Vienna and
London from 50 to 80 per cent of all the children at the clinics present
signs of rickets. It is a comparatively rare disease in Canada. In the cities
of the United States it is very prevalent, particularly among the children of
the negro and of the Italian races. Want of sunlight, impure air, confinement,
and lack of exercise are important factors. Prolonged lactation and suckling
the child during pregnancy are accessory influences in some cases.
There is no evidence that the disease is hereditary.
Eickets affects male and female children equally. It is a disease of the
first and second years of life, rarely beginning before the sixth month. Jenner
has described a late rickets, in which form the disease may not appear until
the ninth or even until the twelfth year, or later (the osteomalacia of pu-
berty). Eickets has been regarded as a manifestation of congenital syphilis
(Parrot). Syphilitic bones rarely, if ever, present the spongy tissue peculiar
to rickets, and rhachitic bones never show the multiple osteophytes of syphi-
lis. " Syphilis modifies rickets; it does not create it" (Cheadle). A faulty
diet is the essential factor in the production of the disease. Like scurvy,
rickets may be found in the families of the wealthy under perfect hygienic
conditions. It is most common in children fed on condensed milk, the vari-
ous proprietary foods, cow's milk, and food rich in starches. " An analysis
of the foods on which rickets is most frequently and certainly produced shows
invariably a deficiency in two of the chief elements so plentiful in the standard
food of young animals — ^namely, animal fat and proteid" (Cheadle). Bland
Sutton's interesting experiment with the lion's cubs at the " Zoo " illustrates
this point. When milk, pounded bones, and cod-liver oil were added to the
meat diet the rickets disappeared, and for the first time in the history of the
societ}^ the cubs were reared. Associated with the defect in food is a lack of
proper assimilation of the lime salts.
Morbid Anatomy. — Glisson's original description of the external appear-
ances of the body of a rickety child is remarkably complete; indeed, the
entire monograph is an enduring monument to the skill and powers of obser-
vation of this great physician, "(1) ko. irregular or unusual proportion of
RICKETS. 427
its parts. The head is evidently larger than normal, and the face fatter in
respect to the other parts. . . . (2) The external members and muscles
of the whole body are seen to be delicate and emaciated, as though consumed
by atrophy or tabes, and this (so far as we know) is always observed in those
dead of this affection. (3) The whole skin, both the true and the fleshy and
fatty layers, is flaccid and rather pendulous, like a loose glove, so that you
think it could hold much more flesh. (4) About the Joints, especially in the
wrists and ankles, there are certain protuberances which, if opened, are seen
to arise, not in the fleshy or membranous parts, but in the ends of the bones
themselves, especially in their epiphyses. (5) The joints, limbs, and habitus
of all these external parts are less firm and rigid, less inflexible than in
other dead bodies, and the neck scarcely becomes rigid, a frigore post mor-
tem, or to a less extent than in other cadavers. (6) The chest externally is
thin and much narrowed, especially beneath the scapulae, as though com-
pressed from the sides, and the sternum accuminated like the keel of a ship
or the breast of a fowl. (7) The ends of the ribs which join with the
cartilages of the sternum are nodular, like the ends of the wrists and
ankles."
He also describes the prominent abdomen, the enlarged liver, and the
changes in the mesenteric glands.
The bones show the most important changes, particularly the ends of the
long bones and the ribs. Between the shaft and epiphyses a slight bulging
is apparent, and on section the zone of proliferation, which normally is
represented by two narrow bands, is greatly thickened, bluish in color, more
irregular in outline, and very much softer. The width of this cushion of
cartilage varies from 5 to 15 mm. The line of ossification is also irregular
and more spongy and vascular than normal. The periosteum strips off very
readily from the shaft, and beneath it there may be a spongy tissue not
unlike decalcified bone. The practical outcome of these changes is an im-
perfect ossification, so that the bone has neither the natural rate of growth
nor the normal firmness. In the cranium there may be large areas, particu-
larly in the parieto-occipital region, in which the ossification is delayed, pro-
ducing the so-called cranio-tabes, so that the bone yields readily to pressure
with the finger. There are localized depressed spots of atrophy, which, on
pressure, give the so-called " parchment crackling." Flat hyperostoses arise
on the outer table, particularly on the frontal and parietal bones, producing
the characteristic broad forehead with prominent frontal eminences, a con-
dition sometimes mistaken for hydrocephalus.
Kassowitz, the leading authority on the anatomy of rickets, regards the
hypersemia of the periosteum, the marrow, the cartilage, and of the bone
itself as the primary lesion, out of which all the others arise. This disturbs
the normal development of the growing bone and excites changes in that
already formed. The cartilage cells in consequence proliferate, the matrix
is softer, and as a result the bone which is formed from this unhealthy car-
tilage is lacking in firmness and solidity. In the bone already formed this
excessive vascularity exaggerates the normal processes of absorption, so that
the relation between removal and deposition is disturbed, absorption taking
place too rapidly. The new material is poor in lime salts. Kassowitz has
proved experimentally that hypergemia of bone results in defective deposition
428 CONSTITUTIONAL DISEASES.
of lime salts. It is interesting to note that Glisson attributed rickets to
disturbed nutrition by arterial blood, and believed the changes in the long
bones to be due to excessive vascularity.
The chemical analysis of rickety bones shows a marked diminution in
the calcareous salts, which may be as low as 25 or 35 per cent.
The liver and spleen are usually enlarged, and sometimes the mesenteric
glands. As Gee suggests, these conditions probably result from the general
state of the health associated with rickets. Beneke has described a relative
increase in the size of the arteries in rickets.
Symptoms. — The disease comes on insidiously about the period of denti-
tion, before the child begins to walk. Mild grades of it are often overlooked
in the families of the well-to-do. In many cases digestive disturbances pre-
cede the appearance of the characteristic lesions, and the nutrition of the
child is markedly impaired. There is usually slight fever, the child i«
irritable and restless, and sleeps badly. If he has already walked, he now
shows a marked disinclination to do so, and seems feeble and unsteady in
his gait. Sir William Jenner has called attention to three general symptoms
of great importance: First, a diffuse soreness of the body, so that the child
cries when an attempt is made to move it, and prefers to keep perfectly still.
This is often a marked and suggestive symptom. Secondly, slight fever
(100° to 101.5°), with nocturnal restlessness, and a tendency to throw off
the bedclothes. This may be partly due to the fact that the general sensi-
tiveness is such that even their weight may be distressing. And, thirdly,
profuse sweating, particularly about the head and neck, so that in the morn-
ing the pillow is found soaked with perspiration.
The tissues become soft and flabby; the skin is pale; and from a healthy,
plump condition, the child becomes puny and feeble. The muscular weak-
ness may be marked, particularly in the legs, and paralysis may be suspected.
This so-called pseudo-paresis of rickets results in part from the flabby, weak
condition of the legs and in part from the pain associated with the move-
ments. Coincident with, or following closely upon, the general symptoms
the characteristic skeletal lesions are observed. Among the first of these to
appear are the changes in the ribs, at the junction of the bone with the car-
tilage, forming the so-called rickety rosary. "When the child is thin these
nodules may be distinctly seen, and in any case can be easily made out by
touch. They very rarely appear before the third month. They may increase
in size up to the second year, and are rarely seen after the fifth year. The
thorax undergoes important changes. Just outside the junction of the car-
tilages with the ribs there is an oblique, shallow depression extending down-
ward and outward. A transverse curve, sometimes called Harrison's groove,
passes outward from the level of the ensiform cartilage toward the axilla, and
may be deepened at each inspiration. It is rendered more prominent by the
eversion and prominence of the costal border. The sternum projects, par-
ticularly in its lower half, forming the so-called pigeon or chicken breast.
These changes in the thorax are not peculiar, however, to rickets, and are
much more commonly associated with h^-pertrophy of the tonsils, or any
trouble which interferes vsdth the free entrance of air into the lungs. The
spine is often curved posteriorly, the processes are prominent; lateral curva-
ture is not so common.
RICKETS. 429
The head of a rickety child usually looks large in proportion both to the
body and the face, and the fontanelles remain open for a long time. There
are areas, particularly in the parieto-occipital regions, in which ossification is
imperfect; and the bone may yield to the pressure of the finger, a condition
to which the term cranio-tahes has been given. The relation of this condition
to rickets is still somewhat doubtful, as it is very often associated with syphi-
lis— in 47 of 100 cases studied by George Carpenter. Coincidently with this,
hyperplasia proceeds in the frontal and parietal eminences, so that thes6 por-
tions of the skull increase in thickness, and may form irregular bosses. In
one type the skull may be large and elongated, with the top considerably
flattened. In another, and perhaps more common case, the shape of the skull,
when seen from above, is rectangular — the caput quadratum. The skull looks
large in proportion to the face. The forehead is broad and square, and the
frontal eminences marked. The anterior fontanelle is late in closing, and
may remain open until the third or fourth year. The skin is thin, the veins
are full and prominent, and the hair is often rubbed from the back of the
skull. In contradistinction to the cranio-tabes is the condition of cranio-
sclerosis, which has also been ascribed to rickets.
On placing the ear over the anterior fontanelle, or in the temporal region,
a systolic murmur may frequently be heard. This condition, first described
by John D. Fisher, of Boston, in 1833, is heard with the greatest frequency
in rickets, but its presence and persistence in perfectly healthy infants have
been amply demonstrated. The murmur is rarely heard after the fifth year,
A knowledge of the existence of this systolic brain murmur may prevent
errors. A case has been reported as an instance of tumor of the brain.
Changes occur in the bones of the face, chiefiy in the maxillse, which are
reduced in size. The normal process of dentition is much disturbed; indeed,
late teething is one of the marked features in rickets. The teeth which appear
may be small and badly formed.
In the upper limbs changes in the scapulae are not common. The clavicle
may be thickened at the sternal end, and there may be thickening near the
attachment of the sterno-cleido muscle. The most noticeable changes are
at the lower ends of the radius and ulna. The enlargement is at the junction-
area of the shaft and epiphysis. Less evident enlargements may occur at the
lower end of the humerus. In severe cases the natural shape of the bones
of the arm may be much altered, since they have had to support the weight of
the child in crawling on the floor. The changes in the pelvis are of special
importance, particularly in female children, as in extreme cases they lead to
great deformity, with narrowing. In the legs, the lower end of the tibia first
hecomes enlarged ; and in slight cases it may alone be affected. In the severe
forms the upper end of the bone, the corresponding parts of the fibula, and
the lower end of the femur become greatly thickened. If the child walks, slight
bowing of the tibiae inevitably results. In more advanced cases the tibiae, and
even the femora, may be arched forward. In other instances the condition of
knock-knee occurs. Unquestionably the chief cause of these deformities is
the weight of the body in walking, but muscular action takes part in it. The
green-stick fracture is not uncommon in the soft bones of rickets.
These changes in the skeleton proceed slowly, and the general s3'Tnptoms
Tary a good deal with their progress. The child becomes more or less ema-
430 CONSTITUTIONAL DISEASES.
ciated, though " fat rickets " is by no means uncommon, and a child may be
well nourished but " pasty " and flabby. Fever is not constant, but in actively
progressing changes in the bone there is usually a slight pyrexia. The abdo-
men is large, " pot-bellied/' due partly to flatulent distention, partly to en-
largement of the liver^ and in severe cases to diminution of the volume of the
thorax. The spleen is often enlarged and readily palpable. The urine is
stated to contain an excess of lime salts, but Jacobi and Barlow say this has
not been proved. No special or peculiar changes, indeed, have as yet been
described. There is usually slight anaemia, the haemoglobin is absolutely and
relatively decreased; a leucocytosis may or may not be present; it is more
common with enlargement of the spleen (Morse). Many rickety children
show marked nervous symptoms; irritability, peevishness, and sleeplessness
are constantly present. Jenner called attention to the close relationship which
existed between rickets and infantile convulsions, particularly to the fits
which occur after the sixth month. Tetany is by no means uncommon. It
involves most frequently the arms and hands; occasionally the legs as well.
Laryngismus stridulus is a common complication, and though not, as some
state, invariably associated, yet it is certainly much more frequent in rickety
than in other children. Severe rickets interferes seriously with the growth
of a child. Extreme examples of rickety dwarfs are not uncommon. Acute
rickets, so called, is in reality a manifestation of scurvy and will be described
with that disease.
Prognosis. — The disease is never in itself fatal, but the condition of the
child is such that it is readily carried off by intercurrent affections, particu-
larly those of the respiratory organs. Spasm of the larynx and convulsions
occasionally cause death. In females the deformity of the pelvis is serious,
as it may lead to difficulties in parturition.
Treatment. — The better the condition of the mother during pregnancy
the less likelihood is there of the development of rickets in the child. Eapidly
repeated pregnancies and suckling of a child during pregnancy seem impor-
tant factors in the production of the disease. Of the general treatment,
attention to the feeding of the child is the first consideration. If the mother
is unhealthy, or can not from any cause nurse the child, a suitable wet-nurse
should be provided, or the child must be artificially fed, in which case cow's
milk, diluted according to the age of the child, should constitute the chief food.
Care should be taken to examine the condition of the stools, and if curds are
present the child is taking too much, or it is not sufficiently diluted. Barley-
water or carefully strained and well-boiled oatmeal gruel form excellent addi-
tions to the milk.
The child should be warmly clad and should be in the fresh air and
sunshine the greater part of the day. It is a " vulgar error " to suppose that
delicate children can not stand, when carefully wrapped up, an even low tem-
perature. The child should be bathed daily in warm water. Careful friction
with sweet oil is very advantageous, and, if properly performed, allays rather
than aggravates the sensitiveness. Special care should be taken to prevent
deformity. The child should not be allowed to walk, and for this purpose
splints applied so as to extend beyond the feet are very effective. Of medi-
cines, phosphorus has been warmly recommended by Kassowitz, and its use
is also advised by Jacobi. The child may be given gr. -^ two or three times
OBESITY. 431
a day, dissolved in olive oil. The best preparation in such cases is the elixir
phosphori, six to ten or twelve minims three times a day (Jacobi). Cod-
liver oil, in doses of from a half to one teaspoonful, is very advantageous.
The syrup of the iodide of iron may be given with the oil. The digestive
disturbances, together with the respiratory and nervous complications, should
receive appropriate treatment.
VIII. OBESITY.
Corpulence, an excessive development of the bodily fat — an "oily dropsy,"
in the words of Lord Byron — is a condition for which we are consulted in
three groups of cases. First, there are persons of both sexes who have an
hereditary tendency to obesity. Secondly, there is an increasing number of
cases of obesity in children, particularly in the United States, associated with
bad habits in eating, and usually carelessness and lack of control on the part
of the parents. Thirdly, and most frequently, we are consulted by women
at the middle period of life, who are troubled with an over-growth of fat.
While as a rule fat is no sign of health, and particularly in children may be
associated with angemia and rickets, on the other hand a great many stout
persons enjoy unusual vigor. Nor is obesity always associated with over-
eating. Many stout persons are light eaters, and chlorotic girls with de-
praved or poor appetites may be very plump. After forty, as Sir James Paget
remarks, we tend to become either thin or fat, and the former are usually
happier and live longer. Too much food and too little exercise are largely
responsible in about half of the cases, but in the hereditary ones these factors
do not prevail, and this is a point to be borne in mind very carefully in the
question of treatment. As Duckworth states, gout is an important agent in
many instances!
A remarkable form seen occasionally is acute obesity in which as much as
seventy pounds in weight may be gained in six or eight months. In one case
it was associated with marked cardiac weakness and extreme dyspnoea on
exertion.
In obesity it is now generally conceded that the carbohydrates, which were
so long blamed, are not at fault, since they are themselves converted into
water and carbon dioxide. On account, however, of the facility with which
they are utilized for the purposes of oxidation, the albuminous elements of
the food are less readily oxidized and not so fully decomposed, and the fat
is in reality separated from them. So, too, the fats themselves are not so
prone to cause obesity as the carbohydrates, being less readily oxidized and
interfering less with the complete metabolism of the albuminous elements.
An extraordinary phenomenon in excessively fat young persons is an un-
controllable tendency to sleep — like the fat boy in Pickwick. I have seen
one instance of it. Caton has reported a case. Sainton (Narcolepsie et
Ohesite, Eev. Neurologique, 1901) regards it as auto-toxic in origin.
Treatment. — We must bear in mind at the outset the injunction of Hip-
pocrates (Aphorism III), speaking of a full habit of body, that extreme
depletions are dangerous, and that the reduction must not be carried to an
extreme. The aphorism of the celebrated George Cheyne (whose history
records one of the most successful instances of the treatment of obesity in
432 CONSTITUTIONAL DISEASES.
literature), quoted at page 463, contains the essence of good sense on the
subject. Put in other words, it reads — We eat too much after forty years
of age.
We are often consulted by persons in whose family obesity prevails to
give rules for the prevention of the condition in children or in women ap-
proaching the climacteric. In the case of children very much may be done
by regulating the diet, reducing the starches and fats in the food, not allow-
ing the children to eat sweets, and encouraging systematic exercises. In the
case of women who tend to grow stout after child-bearing or at the climac-
teric, in addition to systematic exercises, they should be told to avoid taking
too much food, and particularly to reduce the starches and sugars. There
are a number of methods or systems in vogue at present. In the celebrated
one of Banting, the carbohydrates and fats were excluded and the amount
of food was greatly reduced. Ebstein allows more fat.
Oertel's method is given under the treatment of fatty heart. He reduces
the amount of liquid taken, and this is practically, too, the so-called Schwen-
inger cure, in which liquids are allowed only two hours after the food.
Von Noorden's dietar}^ given in his exhaustive article in Nothnagel's
Handbuch, is as follows: Eight o'clock, 80 grammes of lean, cold meat, 25
grammes of bread, one cup of tea, with a spoonful of milk, no sugar. Ten
o'clock, one egg. Twelve o'clock, a cup of strong meat broth. One o'clock,
a small plate of meat soup flavored with vegetables, 159 grammes of lean
meat of one or two sorts, partly fish, partly flesh, 100 grammes of potatoes
with salad, 100 grammes of fresh fruit, or compote without sugar. Three
o'clock, a cup of black coffee. Four o'clock, 200 grammes of fresh fruit.
Six o'clock, a quarter of a litre of milk, if desired, with tea. Eight o'clock,
125 grammes of cold meat, or 180 grammes of meat weighed raw and grilled,
and eaten with pickles or radishes and salad, 30 grammes of Graham bread,
and two or three spoonfuls of cooked fruit without sugar. He believes it
more satisfactory to give in addition to the three meals smaller quantities
of food at shorter intervals, so as to obviate the tendency to weakness which
these patients often experience. In addition he allows twice in the day
a glass of wine. The use of mineral water, weak tea, or lemonade is not
limited at the meal times or in the intervals. An occasional " hunger-day* "
is given.
In the treatment of extreme obesity it is very much better that the patient
should be in hospital, or under the care of a nurse, who will undertake the
proper weighing and administration of the food.
The thyroid extract should be used only in a systematic " cure." Five
grains three times a day is a sufficient dose. In conjunction with the diet and
exercises, it is useful, but it should not be ordered indiscriminately to fat
persons.
Adiposis Dolorosa {Dercuras Disease). — "A disorder characterized by
irregular, s}^nmetrical deposits of fatty masses in various portions of the
body, preceded by or attended with pain." It is an affection of women,
occurring at the middle period of life. In association with neuralgic pains,
fatty swellings occur in various parts of the body. The bunches of fat may
form huge masses, pendulous, and of a pultaceous consistence. They do not
occur on the hands, feet, or face. It differs from other forms of obesitv in
OBESITY. 433
its lumpy distribution, and in the nervous disturbances in the form of pains
and parsesthesias. The nature of the trouble is unknown.
In a case of Burr's, and in one of Dercum's, the thyroid gland showed
atrophic changes. Dercum tells me that he has seen improvement from the
use of the thyroid extract, and in one case there was a complete disappear-
ance of all the neuritic symptoms, and a great diminution in the size of the
fatty deposits.
29
SECTION V.
DISEASES OF THE DIGESTIVE SYSTEM.
A. DISEASES OF THE MOUTH.
STOMATITIS.
(1) Acute Stomatitis. — Simple or erythematous stomatitis, the common-
est form, results from the action of irritants of various sorts. Frequent at
all ages, in children it is usually associated with dentition and with gastro-
intestinal disturbance, particularly in ill-nourished, unhealthy subjects; in
adults it may follow the abuse of tobacco, or the use of too hot or too highly
seasoned food; it is a concomitant of indigestion, or of the specific fevers.
The affection may be limited to the gums and lips or may extend over
the whole surface of the mouth and include the tongue. There is at first
superficial redness and dryness of the membrane, followed by increased secre-
tion and swelling of the tongue, which is furred, and indented by the teeth.
There is rarely any constitutional disturbance, but in children there may be
slight elevation of temperature. The condition is sufficient to cause consid-
erable discomfort, sometimes amounting to actual distress and pain, particu-
larly in mastication.
In infants the mouth should be carefully sponged after each feeding. A
mouth-wash of borax or the glycerin of borax may be used, and in severe
cases, which tend to become chronic, a dilute solution of nitrate of silver (3
or 4 grains to the ounce) may be applied.
(2) Aphthous Stomatitis. — This form, also known as follicular or vesicu-
lar stomatitis, is characterized by the presence of small, slightly raised spots,
from 2 to 4 mm. in diameter, surrounded by reddened areolse. The spots
appear first as vesicles, which rupture, leaving small ulcers with grayish bases
and bright-red margins. They are seen most frequently on the inner surfaces
of the lips, the edges of the tongue, and the cheeks. They are seldom present
on the mucous membrane of the pharynx. This form is met with most often
in children under three years. It may occur either as an independent affec-
tion or in association with any one of the febrile diseases of childhood or
with an attack of indigestion. The crop of vesicles comes out with great
rapidity and the little ulcers may be fully formed within twenty-four hours.
The child complains of soreness of the mouth and takes food with reluctance.
The buccal secretions are increased, and the breath is heavy, but not foul.
The constitutional symptoms are usually those of the disease with which the
aphthae are associated. The disease must not be confounded with thrush.
434
DISEASES OF THE MOUTH. 435
No special parasite has been found in connection with it. It is not a serious
condition, and heals rapidly with the improvement of the constitutional state.
In severe cases it may extend to the pillars of the fauces and to the pharynx,
and produce ulcers which are irritating and difficult to heal.
Each ulcer should be touched with nitrate of silver and the mouth should
be thoroughly cleansed after taking food. A wash of chlorate of potassium,
or of borax and glycerin, may be used. The constitutional symptoms should
receive careful attention.
Here may be mentioned a curious affection which has been observed chiefly
in southern Italy, and which is characterized by a pearly-colored membrane
with induration, immediately beneath the tongue on the frgenum (Riga's
disease). There may be much induration and ultimately ulceration. It
occurs in both healthy and cachetic children, usually about the time of the
eruption of the first teeth. It is sometimes epidemic.
(3) Ulcerative Stomatitis. — This form, which is also known by the names
of fetid stomatitis^ or putrid sore mouthy occurs particularly in children after
the first dentition. It may prevail as a wide-spread epidemic in institutions
in which the sanitary conditions are defective. It has been met with in jails
and camps. . Insufficient and unwholesome food, improper ventilation, and
prolonged damp, cold weather seem to be special predisposing causes. Lack
of cleanliness of the mouth, the presence of carious teeth, and the collection
of tartar around them favor the occurrence of the disease. The affection
spreads like a specific disease, but the microbe has not yet been isolated. It
has been held that the disease is the same as the foot-and-mouth disease of
cattle, and that it is conveyed by the milk, but there is no positive evidence
on these points. Payne suggests that the virus is identical with that of con-
tagious impetigo.
The morbid process begins at the margin of the gums, which become
swollen and red, and bleed readily. Ulcers form, the bases of which are
covered with a grayish- white, firmly adherent membrane. In severe cases, the
teeth may become loosened and necrosis of the alveolar process may occur.
The ulcers extend along the gum-line of the upper and lower jaws ; the tongue,
lips, and mucosa of the cheeks are usually swollen, but rarely ulcerated. There
is salivation, the breath is foul, and mastication is painful. The submaxillary
lymph-glands are enlarged. An exanthem may break out and be mistaken
for measles. The constitutional sjnnptoms are often severe, and in debilitated
children death sometimes occurs;
In the treatment of this form of stomatitis chlorate of potassium has been
found to be almost specific. It should be given in doses of 10 grains, three
times a day, to a child, and to an adult double that amount. Locally it may
be used as a mouth-wash, or the powdered salt may be applied directly to the
ulcerated surfaces. When there is much fetor, a solution of potassium per-
manganate may be used as a wash, and an application of nitrate of silver
made to the ulcers.
There are several other varieties of ulcerative sore mouth, which differ
entirely from this form. Ulcers of the mouth are common in nursing women,
and are usually seen on the mucous membrane of the lips and cheeks. They
arise from the mucous follicles, and are from 3 to 5 mm. in diameter. They
may cause little or no inconvenience; but in some instances they are very
436 DISEASES OF THE DIGESTIVE SYSTEM.
painful and interfere seriously with the taking of food and its mastication.
As a rule they heal readily after the application of nitrate of silver, and the
condition is an indication for tonics, fresh air, and a better diet.
Eecurring outbreaks of an herpetic^ even pemphigoid, stomatitis are seen
in neurotic individuals {stomatitis neurotica chronica, Jacobi). It may pre-
cede or accompany the fatal form of pemphigus vegetans.
Parrot describes the occasional appearance in new-born, debilitated chil-
dren of small ulcers symmetrically placed on the hard palate on either side
of the middle line. They rarely heal, but tend to increase in size, and may
involve the bone.
Bednar's aphthae consist of small patches and ulcers on the hard palate,
caused as a rule in young infants by the artificial nipple or the nurse's
finger.
(4) Parasitic Stomatitis {Thrush; Soor; Muguet). — This affection, most
commonly seen in children, is dependent upon a fungus, Saccharomyces
albicans, called by Robin O'idium albicans. It belongs to the order of
yeast fungi, and consists of branching filaments, from the ends of which
ovoid torula cells develop. The disease does not arise apparently in a normal
mucosa. The use of an improper diet, uncleanliness of the mouth, the acid
fermentation of remnants of food, or the occurrence, from any cause, of ca-
tarrhal stomatitis predispose to the growth. In institutions it is frequently
transmitted by unclean feeding-bottles, spoons, etc. It is not confined to
children, but is met with in adults in the final stages of fever, in chronic
tuberculosis, diabetes, and in cachectic states. The parasite grows in the
upper layers of the mucosa, and the filaments form a dense felt-work among
the epithelial cells. The disease begins on the tongue and is seen in the form
of slightly raised, pearly-white spots, which increase in size and gradually
coalesce. The membrane thus formed can be readily scraped off, leaving an
intact mucosa, or, if the process extends deeply, a bleeding, slightly ulcerated
surface. The disease spreads to the cheeks, lips, and hard palate, and may
involve the tonsils and pharynx. In very severe cases the entire buccal mucosa
is covered by the grayish-white membrane. It may even extend into the
oesophagus and, according to Parrot, to the stomach and caecum. It is occa-
sionally met with on the vocal cords. Robust, well-nourished children are
sometimes affected, but it is usually met with in enfeebled, emaciated infants
with digestive or intestinal troubles. In such cases the disease may persist
for months.
The affection is readily recognized, and must not be confounded with
aphthous stomatitis, in which the ulcers, preceded by the formation of vesi-
cles, are perfectly distinctive. In thrush the microscopical examination shows
the presence of the characteristic fungus throughout the membrane. In this
condition, too, the mouth is usually dry — a striking contrast to the salivation
accompanying aphthse.
Thrush is more readily prevented than removed. The child's mouth
should be kept scrupulously clean, and, if artificially fed, the bottles should
be thoroughly sterilized. Lime-water or any other alkaline fiuid, such as the
bicarbonate of soda (a drachm to a tumbler of water), may be employed.
When the patches are present these alkaline mouth-washes may be continued
after each feeding. A spray of borax or of sulphite of soda (a drachm to
DISEASES OF THE MOUTH. 437
the ounce) or the black wash with glycerine may be employed. The perman-
ganate of potassium is also useful. The constitutional treatment is of equal
importance, and it will often be found that the thrush persists, in spite of
all local measures, until the general health of the infant is improved by
change of air or the relief of the diarrhoea, or, in obstinate cases, the substi-
tution of a natural for the artificial diet.
(5) Gangrenous Stomatitis (Cancrnm Oris; Noma). — An affection char-
acterized by a rapidly progressing gangrene, starting on the gums or cheeks,
and leading to extensive sloughing and destruction. This terrible, but for-
tunately rare, disease is seen onl}'^ in children under very unsanitary conditions
or during convalescence from the acute fevers. It is more common in girls
than in boys. It is met with between the ages of two and five years. In at
least one-half of the cases the disease has occurred during convalescence from
measles. Cases have been seen also after scarlet fever and typhoid. The
mucous membrane is first affected, usually of the gums or of one cheek. The
process begins insidiously, and when first seen there is a sloughing ulcer of
the mucous membrane, which spreads rapidl}^ and leads to brawny induration
of the skin and adjacent parts. The sloughing extends, and in severe cases
the cheek is perforated. The disease may spread to the tongue and chin;
it may invade the bones of the jaws and even involve the eyelids and ears. In
mild cases an ulcer forms on the inner surface of the cheek, which heals or
may perforate and leave a fistulous opening. Naturally in such a severe
affection the constitutional disturbance is very great, the pulse is rapid, the
prostration extreme, and death usually takes place within a week or ten days.
The temperature may reach 103° or 104°. Diarrhoea is usually present, and
aspiration pneumonia often develops. H. R. Wharton has described a case
in which there was extensive colitis. Bishop and Ryan have isolated an organ-
ism which' resembles in all points the diphtheria bacillus of reduced virulence.
The treatment of the disease is unsatisfactory. In many cases the onset
is so insidious that there is an extensive sloughing sore when the case first
comes under observation. Destruction of the sore by the cautery, either the
Paquelin or fuming nitric acid, is the most effectual. Antiseptic applications
should be made to destroy the fetor. The child should be carefully nourished
and stimulants given freely.
(6) Mercurial Stomatitis (Ptyalism). — It occurs chiefly in persons who
have a special susceptibility, and rarely now as a result of the excessive iise
of the drug. It is met with also in persons whose occupation necessitates
the constant handling of mercury. It often follows the administration of
repeated small doses. Thus, a patient with heart-disease who was ordered
an eighth of a grain of calomel every three hours for diuretic purposes had,
after taking eight or ten doses, a severe stomatitis, which persisted for several
weeks. I have known it to follow the administration of small doses of gray
powder. The patient complains first of a metallic taste in the mouth, the
gums become swollen, red, and sore, mastication is difficult, the salivary glands
become enlarged and painful, and there is a great increase in their secretion.
The tongue is swollen, the breath has a foul odor, and, if the affection pro-
gresses, there may be ulceration of the mucosa, and, in rare instances, necrosis
of the jaw. Although troublesome and distressing, the disease is rarely seri-
ous, and recovery usually takes place in a couple of weeks. Instances in
438 DISEASES OF THE DIGESTIVE SYSTEM.
which the teeth become loosened or detached or in wliich the inflammation
extends to the pharynx and Eustachian tubes are rarely seen now.
The administration of mercury should be susj^ended so soon as the gums
are " touched.'' Mild cases of the affection subside within a few days and
require only a simple mouth-wash. In severer cases the chlorate of potassium
may be given internally, and used to rinse the mouth. The bowels should be
freely opened; the patient should take a hot bath every evening and should
drink plentifully of alkaline mineral waters. Atropine is sometimes service-
able, and may be given in doses of ^hr of a grain twice a day. Iodine is also
recommended. When the salivation is severe and protracted, the patient be-
comes much debilitated and anaemic, so that a supporting treatment is indi-
cated. The diet is necessarily liquid, for the patient finds the chief difficulty
in taking food. If the pain is severe a Dover powder may be given at
night.
Here may be appropriately mentioned the influence of stomatitis, particu-
larly the mercurial form, upon the developing teeth of children. The con-
dition known as erosion, in which the teeth are honeycombed or pitted owing
to defective formation of enamel, is indicative, as a rule, of infantile stoma-
titis. Such teeth must be distinguished carefully from those of congenital
S3^hilis, which may of course coexist, but the two conditions are distinct. The
honeycombing is frequentty seen on the incisors ; but, according to Jonathan
Hutchinson, the test teeth of infantile stomatitis are the first permanent
molars, then the incisors, " which are almost as constantly pitted, eroded, and
of bad color, often showing the transverse furrow which crosses all the teeth
at the same level." Magitot regards these transverse furrows as the result
of infantile convulsions or of severe illness during early life. He tliinks they
are analogous to the furrows on the nails which so often follow a serious
disease.
(7) Geographical Tongue (Eczema of the Tongue). — A remarkable des-
quamation of the superficial epithelium of the tongue in circinate jDatches,
which spread while the central portions heal. Fusion of patches leads to areas
with sinuous outlines. When extensive the tongue may be covered with these
areas, like a geographical map. The affection causes a good deal of itching
and heat, and may be a source of much mental worry to the patients, who
often dread lest it may be a commencing cancer.
The etiology of the disease is unknown. It occurs in infants and chil-
dren, and it is not very infrequent in adults. It has been regarded as a gouty
manifestation, and transient attacks may accompany indigestion. It is very
liable to relapse. In adults it may prove very obstinate, and I know of one
instance in which the disease persisted in spite of all treatment for more than
two years. Solutions of nitrate of silver give the most satisfactory results in
relieving the intense burning.
There is a troublesome affection, not unlike the geographical tongue, as
the patients have the same sense of burning and pain on eating. It is a
superficial glossitis, limited usually to the border and point of the tongue,
which presents irregular reddish spots, looking as if the epithelium was re-
moved, and the papillie are reddened and swollen. The condition is sometimes
known as Moller's glossitis. Local treatment with nitrate of silver as a rule
gives relief.
DISEASES OF THE MOUTH. 439
(8) Leukoplakia buccalis. — Samuel Plumbe described the condition as
icthyosis lingualis. It has also been called buccal psoriasis and I euco -keratosis
mucosa? oris. The following forms occur: (a) Small white spots upon the
tongue, slightly raised, even papillomatous — ^lingual corns. (&) Diffuse thick-
ening of the epithelial coating of the tongue, either a thin, bluish-white color
or opaque white, depending upon the thickness. It is patchy, and more often
upon the dorsum and sides, (c) Diffuse oral leukoplakia, a remarkable con-
dition in which the roof of the mouth, the gums, lips, and cheeks are covered
with an opaque white, sometimes smooth, sometimes fissured, rugose layer.
In this wide-spread form the tongue may be spared. The visible mucosa of
the lips may be involved, and occasionally the genital mucosa.
While appearing spontaneously, the condition is most common in heavy
smokers, and has been called smoker's tongue. Epithelioma occasionally
starts from the localized patches. A majority of the patients have had syphi-
lis, but the condition does not yield, as a rule, to specific treatment. There
is a glossy, fiat atrophy of the posterior part of the tongue, also believed to
be syphilitic (Virchow).
Leukoplakia is a very obstinate affection. All irritants, such as smoke and
very hot food, should be avoided. Local treatment with one-half-per-cent
corrosive sublimate or a one-per-cent chromic-acid solution has been recom-
mended. The propriety of active local treatment is doubtful. Papillomatous
outgrowths should be cut off. The X-rays may be tried. The most extensive
form may disappear spontaneously.
(9) Fetor Oris. — The practitioner is frequently consulted for foul breath,
and is daily made aware of its wide-spread prevalence. Too often he is himself
the subject of the condition, to the disgust of his patients, with whom he
has to come into such close contact. It is impossible to give even a list of all
the causes which are mentioned. The following are a few of the more im-
portant: (1) In connection with indigestion and the associated catarrhal
disturbances in the mouth, pharynx, and stomach. The breath is " heavy,"
as the mothers say. A simple mouth-wash and a mercurial purge suffice to .
remove it. In a more serious disease of the stomach the breath may be foul,
and occasionally, in sloughing cancer, horribly stinking. (2) Local condi-
tions in the mouth: (a) All the forms of stomatitis. Smokers should re-
member that, apart altogether from the smell of tobacco, their breath in the
morning is usually, to say the least, "heavy," (&) Pyorrhoea alveolaris.
This is the most common cause of foul breath in adults, and is almost con-
stantly present after middle life, causing a perfectly distinctive odor only too
well known to all of us. To test for the presence draw a bit of stout thread
or the edge of a sheet of paper high up between the teeth and the gums and
then smell it. Scrupulous treatment of the gums by a dentist is needed, and
daily scouring, etc. (3) The tonsillar diseases. In the crypts of the tonsils
the epithelial debris accumulates, and, invaded by micro-organisms, gradually
forms the little round or triangular bodies which can be squeezed out of the
lacunge, and when pressed between the fingers smell like Limburger cheese.
The fetor oris from this cause is quite distinctive. To test the presence in
child or adult, smell the finger after it has been rubbed firmly upon the tonsil.
Local treatment is needed. (4) Decayed teeth, the foul odor of which is
quite distinct from that of pyorrhoea or chronic tonsillitis, (5) Eespiratory.
440 DISEASES OF THE DIGESTIVE SYSTEM.
Many diseases of the nose, larjmx, bronchi, and lungs are associated with foul
breath. (6) Heemic. The halitus — the expired air from the lung — ma}^ be
impregnated with odors from the blood. Of this there are many well-known
instances.
For practical purposes, it is to be remembered that pyorrhoea alveolaris
and what is called chronic lacunar tonsillitis are the two most common causes
of foul breath.
(10) Oral Sepsis. — To William Hunter, of Charing Cross Hospital, is due
the credit of insisting upon the importance of the mouth as the chief channel
of entrance of the pyogenic organisms, and as itself the seat of septic pro-
cesses. Necrosed teeth, pyorrhoea alveolaris, gingivitis, alveolar abscess, etc.,
are present in a great many people. A systemic infection may follow or the
general health may be lowered by the continuous production of pus. In ex-
tensive pyorrhoea alveolaris the daily amount of pus must be considerable,
and there can be no question that it has a debilitating influence on the general
health and is sometimes associated with a moderate anemia and with a pasty
complexion. Hunter describes septic gastritis and septic enteritis as common
sequences ; indeed, he regards appendicular, pleuritic, gall-bladder and pyelitic
inflammations as forms of " medical sepsis " due largely to infection from
the mouth. One form of pernicious ana?mia — infective hsemolytic antemia —
he believes to be due to oral sepsis, or an infective glossitis. Of the 20 cases
of pernicious anaemia which I had under observation in 1904, pyorrhoea
alveolaris was present in more than half, but not one presented the infec-
tive glossitis. Certain types of nephritis are also believed to be due to oral
infection.
There is no question of the importance of the subject, and we should insist
upon scrupulous cleanliness of the mouth and teeth, particularly clearing
away the tartar and the pockets of pus. An adult should have his teeth
cleansed in this way by a dentist once a month. We should, too, have less
delicacy in telling our friends in whom the odor of the breath reveals the
presence of the pj'orrhcea. (See B. M. J., November 19, 1904.)
(11) Affections of the mucous glands are not very common. In catarrhal
troubles in children and in measles they may be swollen. They are enlarged
and very prominent in Mikulicz's disease, with chronic symmetrical enlarge-
ment of the salivary and lachrymal glands. There is a singular affection of
the mucous glands of the lips, chiefly of the lower, with much swelling and
infiltration. It was described by Volkmann, and has been called Balz's dis-
ease. The mucous glands are enlarged, the ducts much dilated, and on
pressure a mucoid or muco-purulent secretion may exude. The skin over the
lips may be reddened and swollen.
B, DISEASES OE THE SALIVARY GLANDS.
1. Supersecretion (Ptyalism) . — The normal amount of saliva varies from
2 to 3 pints in the twenty-four hours. The secretion is increased during the
taking of food and in the physiological processes of dentition. A great in-
crease, to which the term ptyalism is applied, is met with under many cir-
cumstances. It occurs occasionally in mental and nervous affections and in
DISEASES OF THE SALIVARY GLANDS. 441
rabies. Occasionally it is seen in the acute fevers, particularly in small-pox.
It occurs sometimes with disease of the pancreas. It has been met with
during gestation, usually early, though it may persist throughout the entire
course. It has been known to occur at each menstrual period; and, lastly,
it is a common effect of certain drugs. Mercury, gold, copper, the iodine
compounds, and (among vegetable remedies) jaborandi, muscarin, and to-
bacco excite the salivary secretion. Of these we most frequently see the
effect of mercury in producing ptyalism. The salivation may be present with-
out any inflammation of the mouth.
2. Xerostomia (Arrest of the Salivary and Buccal Secretions; Dry
Mouth). — In this condition, first described by Jonathan Hutchinson, the
secretions of the mouth and salivary glands are suppressed. The tongue is
red, sometimes cracked, and quite dry; the mucous membrane of the cheeks
and of the palate is smooth, shining, and dry; and mastication, deglutition,
and articulation are very difficult. The condition is not common. A majority
of the cases are in women, and in several instances have been associated with
nervous phenomena. The general health, as a rule, is unimpaired. Hadden
suggests that it is due to involvement of some centre which controls the
secretion of the salivary and buccal glands. In one case a man aged thirty-
two had a peculiar growth in the mouth, which proved to be the remnants
of food ; owing to the absence of any salivary or buccal secretions, it collected
along the gums, and became hardened and adherent.
3. Inflammation of the Salivary Glands.
(a) Specific Parotitis. (See Mumps.)
(h) Symptomatic parotitis or parotid huho occurs:
( 1 ) In the course of the infectious fevers — typhus, typhoid, pneumonia,
pyasmia, etc. In ordinary practice it occurs oftenest, perhaps, in typhoid
fever. It is the result either of septic infection through the blood, or the
inflammation, in many cases, passes up the salivary duct, and so reaches the
gland. The process is usually very intense and leads rapidly to suppuration.
It is, as a rule, an unfavorable indication in the course of a fever. Parotitis
may occur in secondary syphilis.
(3) In connection with injury or disease of the abdomen or pelvis, a
condition to which Stephen Paget has called special attention. Of 101 cases
of this kind, " 10 followed injury or disease of the urinary tract, 18 were
due to injury or disease of the alimentary canal, and 23 were due to injury
or disease of the abdominal wall, the peritonseum, or the pelvic cellular tissue.
The remaining 50 were due to injury, disease, or temporary derangement of
the genital organs." By temporary derangement is meant slight injuries or
natural processes — a slight blow on the testis, the introduction of a pessary,
menstruation, or pregnancy. The etiology of this form of parotitis is obscure ;
but Bucknell has brought forward strong evidence to show that in all these
cases infection takes place through the duct.
(3) In association with facial paralysis, as in a case of fatal peripheral
neuritis described by Gowers; in diabetes and chronic metallic poisoning.
In the treatment of parotid bubo the application of half a dozen leeches
will sometimes reduce the inflammation and promote resolution. When sup-
puration seems inevitable hot fomentations should be applied. A free in-
cision should be made early.
30
442 DISEASES OF THE DIGESTIVE SYSTEM.
(c) Chronic parotitis, a condition in which the glands are enlarged, rarely
painful, may follow inflammation of the throat or mumps. Salivation may
be present. It may be due to lead, mercury, or potassium iodide. It occurs
also in chronic Bright's disease and in secondary syphilis. S}T.nmetrical en-
largement of the parotids of moderate extent is not very uncommon among
hospital patients. I have seen three instances this year (1904—^05). I saw
one case, with Halsted, in which for several years the glands had been greatly
enlarged, forming prominent painless tumors.
(d) Mikulicz's Disease. — In 1892 Mikulicz described an enlargement of
the salivary, laehrjonal, and buccal glands, persisting for years without any
special cause. A good many cases have now been reported. In my patient,
a girl of eleven, the spleen was also enlarged. She died of chronic tubercu-
losis, and before death the enlargement of the salivary glands had disap-
peared. The lachrymal glands were completely sclerotic.
(e) Gaseous Tumors of Steno's Duct and of tlie Parotid Gland. — In glass-
blowers and musicians Steno's duct may become inflated with air and form
a tumor the size of a nut or of an egg. Some have contained a mixture of
air, saliva, and pus. In rare cases there are gaseous tumors of the glands,
which give a sensation of crepitation on palpation.
C. DISEASES OE THE PHARYNX.
(1) Circulatory Disturbances. — {a) Hypermnia is common in acute and
chronic affections of the throat, and is frequently seen as a result of the irri-
tation of tobacco smoke, and from the constant use of the voice. Venous
stasis is seen in valvular disease of the heart, and in mechanical obstruction
of the superior vena cava by tumor or aneurism. In aortic insufficiency the
capillary pulse may sometimes be seen and the intense throbbing of the in-
ternal carotid may be mistaken for aneurism.
(&) HcBmorrhage is found in association with bleeding from other mucous
surfaces, or it is due to local causes — granulations or vegetations. It may
be mistaken for hsemorrhage from the hmgs or stomach. Sometimes the
patient finds the pillow stained in the morning with bloody secretion. The
condition is rarely serious, and requires only suitable local treatment. Occa-
sionally a haemorrhage takes place into the mucosa, producing a pharyngeal
hsematoma. I have thrice seen a condition of the uvula resembling haemor-
rhagic infarction. One was in a patient with acute rheumatism, to whom
large doses of salicylic acid had been given; the other two were instances of
peliosis rheumatica, in both of which partial sloughing of the uvula took
place.
(c) (Edema. — An infiltrated o?dematous condition of the uvula and adja-
cent parts is not very uncommon in conditions of debility, in profound
anaemia, and in Bright's disease. The uvula is sometimes from this cause
enormously enlarged, whence may arise difficulty in swallowing or in
breathing.
(2) Acute Pharyngitis (Sore Throat; Angina Simplex). — The entire
pharyngeal structures, often with the tonsils, are involved. The condition
may follow cold or exposure. In other instances it is associated with con-
DISEASES OF THE PHARYNX. 443
stitutional states, such as rheumatism or gout, or with digestive disorders.
The patient complains of uneasiness and soreness in swallowing, of a feeling
of tickling and dryness in the throat, together with a constant desire to hawk
and cough. Frequently the inflammation extends into the larynx and pro-
duces hoarseness. Not uncommonly it is only part of a general naso-pharyn-
geal catarrh. The process ma}^ pass into the Eustachian tubes and cause
slight deafness. There is stiffness of the neck, the lymph-glands of which
may be enlarged and painful. The constitutional symptoms are rarely sefere.
The disease sets in with a chilly feeling and slight fever; the pulse is in-
creased in frequency. Occasionally the febrile symptoms are more severe,
particularly if the tonsils are specially involved. The examination of the
throat shows general congestion of the mucous memlDrane, which is dry and
glistening, and in places covered with sticky secretion. The uvula may be
much swollen.
Acute pharyngitis lasts only a few days and requires mild measures. If
the tonsils are involved and the fever is high, aconite or sodium salicylate may
be given. Guaiacum also is beneficial; but in a majority of the cases a
calomel purge or a saline aperient and inhalations with steam meet the
indications.
(3) Chronic Pharyngitis. — This may follow repeated acute attacks. It
is very common in persons who smoke or drink to excess, and in those who
use the voice very much, such as clergymen, hucksters, and others. It is
frequently associated with chronic nasal catarrh. The naso-pharynx and the
posterior wall are the parts most frequently affected. The mucous membrane
is relaxed, the venules are dilated, and roundish bodies, from 2 to 4 mm.
in diameter, reddish in color, project to a variable distance beyond the mucous
membrane. These represent the proliferations of lymph tissue about the
mucous glands. They may be very abundant, forming elongated rows in the
lateral walls of the pharynx. With this there may be a dry glistening state
of the pharyngeal mucosa, sometimes known as pharyngitis sicca. The pillars
of the fauces and the uvula are often much relaxed. The secretion forms
at the back of the pharynx and the patient may feel it drop down from the
vault, or it is tenacious and adherent, and is only removed by repeated efforts
at hawking.
In the treatment, special attention must be paid to the general health.
If possible, the cause should be ascertained. The condition is almost con-
stant in smokers, and can not be cured without stopping the use of tobacco.
The use of food either too hot or too much spiced should be forbidden. When
it depends upon excessive exercise of the voice, rest should be enjoined. In
many of these cases change of air and tonics help very much. In the local
treatment of the throat gargles, washes, and pastilles of various sorts give
temporary relief, but when the hypertrophic condition is marked the spots
should be thoroughly destroyed by the galvano-cautery. In many instances
this affords great and permanent relief, but in others the condition persists,
and as it is not unbearable, the patient gives up all hope of permanent relief.
(4) Ulceration of the Pharynx. — (a) Follicular. The ulcers are usually
small, superficial, and generally associated with chronic catarrh.
(&) Syphilitic. Most frequently painless and situated on the posterior
wall of the pharynx, they occur in the secondary stage as small, shallow ex-
444 DISEASES OF THE DIGESTIVE SYSTEM.
cavations with the mucous patches. In the tertiary stage they are due to
erosion of gummata, and in healing they leave whitish cicatrices.
(c) Tuberculous. Not very uncommon in advanced cases of phthisis; if
extensive, they form one of the most distressing features of the disease. The
ulcers are irregular, with ill-defined edges and grayish-yellow bases. The pos-
terior wall of the pharyns may have an eroded, worm-eaten appearance. These
ulcers are, as a rule, intensely painful. Occasionally the primary disease is
about the tonsils and the pillars of the fauces.
(d) Ulcers occur in connection with pseudo-membranous inflammation,
particularly the diphtheritic. In cancer and in lupus ulcers are also present.
(e) Ulcers are met with in certain of the fevers, particularly in
typhoid.
In many instances the diagnosis of the nature of pharyngeal ulcers is
very difficult. The tuberculous and cancerous varieties are readily recog-
nized, but it happens not infrequently that a doubt arises as to the syphilitic
character of an ulcer. In many instances the local conditions may be uncer-
tain. Then other evidences of syphilis should be sought for, and the patient
should be placed on mercury and iodide of potassium, under which remedies
specific ulcers usually heal with great rapidity.
(5) Acute Infectious Phlegmon of the Pharynx. — Under this term Sen-
ator has described cases in which, along with difficulty in swallowing, soreness
of the throat, and sometimes hoarseness, the neck enlarges, the pharyngeal
mucosa becomes swollen and injected, the fever is high, the constitutional
symptoms are severe, and the inflammation passes on rapidly to suppuration.
The symptoms are very intense. The swelling of the phar5mgeal tissues early
reaches such a grade as to impede respiration. Very similar symptoms may
be produced by foreign bodies in the pharynx.
(6) Retro-pharyngeal abscess occurs: (1) In healthy children between
six months and two years of age. The child becomes restless, the voice
changes; it becomes nasal or metallic in tone, and there are pain and diffi-
culty in swalloT\dng. Inspection of the pharynx reveals a projecting tumor
in the middle line, or if it be not visible, it is readily felt, on palpation,
projecting from the posterior wall. This form has been carefully described
by Koplik. (2) As a not infrequent sequel of the fevers, particularly of
scarlet fever and diphtheria. (3) In caries of the bodies of the cervical
vertebrge.
The diagnosis is readily made, as the projecting tumor can be seen, or
felt with the finger on the posterior wall of the pharynx.
(7) Angina Ludovici (Ludwig's Angina; Cellulitis of the Nech). — In
medical practice this is seen as a secondary inflammation in the specific
fevers, particularly diphtheria and scarlet fever. It may, however, occur
idiopathically or result from trauma. It is probably always a streptococcus
infection which spreads rapidly from the glands. The swelling at first is
most marked in the submaxillary region of one side. The symptoms are,
as a rule, intense, and, unless early and . thorough surgical measures are em-
ployed, there is great risk of systemic infection. Semon holds that the vari-
ous acute septic inflammations of the throat — acute oedema of the larynx,
phlegmon of the pharynx and larynx, and angina Ludovici — " represent
degrees varying in virulence of one and the same process.'*
DISEASES OF THE TONSILS. 445
D. DISEASES OF THE TONSILS.
I. ACUTE TONSILLITIS.
I. FOLLICULAR OR LACUNAR TONSILLITIS.
For practical purposes, under this name may be described the various
forms which have been called catarrhal, erythematous, ulcero-membranous,
and herpetic.
Etiology. — The disease is met with most frequently in young persons, but
in children under ten it is less common than the chronic form. It is rare
in infants. Sex has no special influence. Exposure to wet and cold, and
bad hygienic surroundings appear to have a direct etiological connection with
the disease. In so many instances defective drainage has been found asso-
ciated with outbreaks of follicular tonsillitis that sewer-gas is regarded as a
common exciting cause. One attack renders a patient more liable to sub-
sequent infection. The tonsils proper and the adjacent lymphatic tissues
undoubtedly act as portals of entry for micro-organisms, not only in acute
rheumatism but probably in other affections. Packard has called particular at-
tention to acute tonsillitis as a precursor of endocarditis, erythema nodosum,
and chorea. Cheadle describes it as one of the phases of rheumatism in
childhood, with which articular attacks or chorea may alternate. The exist-
ence of pains in the limbs upon which some lay stress is no evidence of the
connection of the affection with rheumatism. A disease so common and
wide-spread as acute tonsillitis necessarily attacks many persons in whose
families rheumatism prevails or who may themselves have had acute attacks.
Mackenzie gives a table showing that, in four successive years more cases
occurred in September than in any other month; in October nearly as many,
with July, August, and November next. In this country it seems more preva-
lent in the spring. So many cases arise within a short time that the disease
may be almost epidemic. It spreads through a family in such a way that it
must be regarded as contagious.
An old notion prevails that there is a definite relation between the tonsils
and the testes and ovaries. F. J. Shepherd has called attention to the cir-
cumstance that acute tonsillitis is a very common affection in newly married
persons. The commonest organism found in tonsillitis is a streptococcus.
Staphylococci also occur. In some cases the bacillus diplitherice of Loeffler
has been found, but it does not always possess the full virulence (see Atypical
Forms of Diphtheria).
Morbid Anatomy. — The lacunas of the tonsils become filled with exuda-
tion products, which form cheesy-looking masses, projecting from the orifices
of the crypts. Not infrequently the exudations from contiguous lacunae
coalesce. The intervening mucosa is usually swollen, deep-red in color, and
may present herpetic vesicles or, in some instances, even membranous exuda-
tion, in which case it may be difficult to distinguish the condition from diph-
theria. The creamy contents of the crypt are made up of micrococci and
epithelial debris.
Symptoms. — Chilly feelings, or even a definite chill, and aching pains in
the back and limbs may precede the onset. The fever rises rapidly, and in the
446 DISEASES OF THE DIGESTIVE SYSTEM.
case of a young child may reach 105° on the evening of the first day. The
patient complains of soreness of the throat and difficulty in swallowing. On
examination, the tonsils are seen to he swollen and the crypts present the
characteristic creamy exudate. The tongue is furred^ the hreath is heavy
and foul, and the urine is higlily colored and loaded with urates. In children
the respirations are usually very hurried, and the pulse is greatly increased
in rapidity. Swallowing is painful, and the voice often becomes nasal. Slight
swelling of the cervical glands is present. In severe cases the symptoms in-
crease and the tonsils become still more swollen. The inflammation gradually
subsides, and, as a rule, within a week the fever departs and the local condition
greatly improves. The tonsils, however, remain somewhat swollen. The pros-
tration and constitutional disturbance are often out of proportion to the
intensity of the local disease.
Complications. — Febrile albuminuria is not uncommon, and even acute
nephritis. Endocarditis and pericarditis ate more rare. It is to be borne in
mind that in a child with fever an apex systolic murmur is almost invariably
present. The disease may extend to the middle ear. A diffuse erythema may
simulate the rash of scarlet fever.
Diagnosis. — It may be difficult to distinguish follicular tonsillitis from
diphtheria. It would seem, indeed, as if there were intermediate forms be-
tween the mildest lacunar and the severer pseudo-membranous tonsillitis. In
the follicular form the individual yellowish-gray masses, separated by the
reddish tonsillar tissue, are very characteristic; whereas in diphtheria the
membrane is of ashy gray, and uniform, not patchy. A point of the greatest
importance in diphtheria is that the membrane is not limited to the tonsils,
but creeps up the pillars of the fauces or appears on the uvula. The diph-
theritic membrane when removed leaves a bleeding, eroded surface; whereas
the exudation of lacunar tonsillitis is easily separated, and there is no erosion
beneath it. In all doubtful cases cultures should be made to determine the
presence or absence of Loeffler's bacillus.
II. SUPPURATIVE TONSILLITIS.
Etiology. — This arises under conditions very similar to those mentioned
in the lacunar form. It may follow exposure to cold or wet, and is particu-
larly liable to recur. It is most common in adolescence. The inflammation
is here more deeply seated. It involves the stroma, and tends to go on to
suppuration.
Symptoms. — The constitutional disturbance ■ is very great. The tempera-
ture rises to 104° or 105°, and the pulse ranges from 110 to 130. Nocturnal
delirium is not uncommon. The prostration may be extreme. There is no
local disease of similar extent which so rapidly exhausts the strength of a
patient. Soreness and dr}Tiess of the throat, with pain in swallowing, are
the symptoms of which the patient first complains. One or both tonsils may
be involved. They are enlarged, firm to the touch, dusky red and oedematous,
and the contiguous parts are also much swollen. The swelling of the glands
may be so great that they meet in the middle line, or one tonsil may even
push the uvula aside and almost touch the other gland. The salivary and
buccal secretions are increased. The glands of the neck enlarge, the lower jaw
DISEASES OF THE TONSILS. 447
is fixed, and tlie patient is unable to open liis mouth. In from two to four
days the enlarged gland becomes softer, and fluctuation can be distinctly felt
by placing one finger on the tonsil and the other at the angle of the jaw. The
abscess points usually toward the mouth, but in some cases toward the phar-
ynx. It may burst spontaneously, affording instant and great relief. Suffo-
cation has followed the rupture of a large abscess and the entrance of the pus
into the larynx. When the suppuration is peritonsillar and extensive, the
internal carotid artery may be opened; but these are, fortunately, very ,rare
accidents.
Treatment. — In the follicular form aconite may be given in full doses. It
acts very beneficially in children. The salicylates, given freely at the outset,
are regarded by some as specific, but I have seen no evidence of such prompt
and decisive action. At night, a full dose of Dover's powder may be given.
The use of guaiacum, in the form of 2-grain lozenges, is warmly recom-
mended. Iron and quinine should be reserved until the fever has subsided.
A pad of spongio-piline or thick flannel dipped in ice-cold water may be
applied around the neck and covered with oiled silk. More convenient still
is a small ice-bag. Locally the tonsils may be treated with the dry sodium
bicarbonate. The moistened fingertip is dipped into the soda, which is then
rubbed gently on the gland and repeated every hour. Astringent preparations,
such as iron and glycerin, alum, zinc, and nitrate of silver, may be tried. To
cleanse and disinfect the throat, solutions of borax or thymol in glycerin and
water may be used.
In suppurative tonsillitis hot applications in the form of poultices and
fomentations are more comfortable and better than the ice-bag. The gland
should be felt-^it can not always be seen — from time to time, and should be
opened when fluctuation is distinct. The progress of the disease may be short-
ened and the patient spared several days of great suffering if the gland is
scarified early. The curved bistoury, guarded nearly to the point with plaster
or cotton, is the most satisfactory instrument. The incision should be made
from above downward, parallel with the anterior pillar. There are cases in
which, before suppuration takes place, the parenchymatous swelling is so
great that. the patient is threatened with suffocation. In such instances either
the tonsil must be excised or tracheotomy performed. Delavan refers to two
cases in which he states that tracheotomy would, under these circumstances,
have saved life. Patients with this affection require a nourishing liquid diet,
and during convalescence iron in full doses.
Early removal of the tonsils should be practised when a child suffers with
recurring attacks, and thorough local treatment should be given to the naso-
pharynx. Particular care should be taken of the child's mouth and throat.
II. CHRONIC TONSILLITIS.
(Chronic Naso-pharyngeal Obstruction ; Mouth-Breathing- ; Aprosexia.)
Under this heading will be considered also hypertrophy of the adenoid
tissue in the vault of the pharynx, • sometimes known as the pharyngeal tonsil,
as the affection usually involves both the tonsils proper and this tissue, and
the symptoms are not to be differentiated.
448 DISEASES OF THE DIGESTIVE SYSTEM.
Chronic enlargement of the tonsillar tissues is an affection of great im-
portance, and may influence in an extraordinary way the mental and bodily
development of children.
Etiology. — Hypertrophy of the tonsillar structures is occasionally congen-
ital. Cases are perhaps most frequent in children, during the third hemi-
decade. It may be associated with a general proliferation of all the lymphoid
tissues of the body — lymphatism. The condition also occurs in young adults,
more rarely in the middle-aged. The enlargement may follow diphtheria or
the eruptive fevers. The frequency of the occurrence of adenoid growths in
the naso-pharynx has been variously stated. Meyer, to whom the profession
is indebted for calling attention to the subject, found them in about one per
cent of the children in Copenhagen, while Chappell found 60 cases in the
examination of 2,000 children in New York. These figures give a very
moderate estimate of the prevalence of the trouble. It occurs equally
in boys and girls, according to some writers with greater prevalence in the
former.
Morbid Anatomy. — The tonsils proper present a condition of chronic
hypertrophy, due to multiplication of all the constituents of the glands. The
lymphoid elements may be chiefly involved without much development of
the stroma. In other instances the fibrous matrix is increased, and the organ
is then harder, smaller, firmer, and is cut with much greater difficulty.
The adenoid growths, which spring from the vault of the pharynx, form
masses varying in size from a small pea to an almond. They may be sessile,
with broad bases, or pedunculated. They are reddish in color, of moderate
firmness, and contain numerous blood-vessels. " Abundant, as a rule, over
the vault, on a line with the fossa of the Eustachian tube, the growths may
lie posterior to the fossa — ^namely, in the depression known as the fossa of
Eosenmiiller, or upon the parts which are parallel to the posterior wall of the
pharynx. The growths appear to spring in the main from the mucous mem-
brane covering the localities where the connective tissue fills in the inequali-
ties of the base of the skull ^' (Harrison Allen), The growths are most
frequently papillomatous with a lymphoid parenchyma. Hypertrophy of the
pharyngeal adenoid tissue may be present without great enlargement of the
tonsils proper. Chronic catarrh of the nose usually coexists.
Symptoms. — The direct effect of chronic tonsillar hypertrophy is the es-
tablishment of mouth-breathing. The indirect effects are deformation of the
thorax, changes in the facial expression, sometimes marked alteration in
the mental condition, and in certain cases stunting of the growth. Woods
Hutchinson has suggested that the embryological relation of these structures
with the pituitary body may account for the interference with development.
The establishment of mouth-breathing is the symptom which first attracts
the attention. It is not so noticeable by day, although the child may present
the vacant expression characteristic of this condition. At night the child's
sleep is greatly disturbed; the respirations are loud and snorting, and there
are sometimes prolonged pauses, followed by deep, noisy inspirations. The
pulse may vary strangely during these attacks, and in the prolonged intervals
may be slow, to increase greatly with the forced inspirations. The alee nasi
should be observed during the sleep of the child as they are sometimes much
retracted during inspiration, due to a laxity of the walls, a condition readily
DISEASES OF THE TONSILS. 449
remedied by the use of a soft wire dilator. Night terrors are common. The
child may wake up in a paroxysm of shortness of breath. Sometimes these
attacks are of great severity and the dyspnoea, or rather orthopnoea, may sug-
gest pressure of enlarged glands on the trachea. Sometimes there is a noc-
turnal paroxysmal cough of a very troublesome character (Balne's cough),
usually excited by lying down. The attacks may occur through the day.
When the mouth-breathing has persisted for a long time definite changes
are brought about in the face, mouth, and chest. The facies is so peculiar
and distinctive that the condition may be evident at a glance. The expression
is dull, heavy, and apathetic, due in part to the fact that the mouth is habitu-
ally left open. In long-standing cases the child is very stupid-looking, re-
sponds slowly to questions, and may be sullen and cross. The lips are thick,
the nasal orifices small and pinched-in looking, the superior dental arch is
narrowed and the roof of the mouth considerably raised.
The remarkable alterations in the shape of the chest in connection with
enlarged tonsils were first carefully studied by Dupuytren (1828), who evi-
dently fully appreciated the great importance of the condition. He noted
" a lateral depression of the parietes of the chest consisting of a depression,
more or less great, of the ribs on each side, and a proportionate protrusion
of the sternum in front." J. Mason Warren (Medical Examiner, 1839) gave
an admirable description of the constitutional symptoms and the thoracic
deformities induced by enlarged tonsils. These, with the memoir of Lambron
(1861), constitute the most important contributions to our knowledge on the
subject. Three types of deformity may be recognized:
(a) The Pigeon ok Chicken Beeast, by far the most common form, in
which the sternum is prominent and there is a circular depression in the
lateral zone (Harrison's groove), corresponding to the attachment of the
diaphragm. The ribs are prominent anteriorly and the sternum is angulated
forward at the manubrio-gladiolar junction. As a mouth-breather is watched
during sleep, one can see the lower and lateral thoracic regions retracted
during inspiration by the action of the diaphragm.
(&) Baerel Chest. — Some children, the subject of chronic naso-pharyn-
geal obstruction, have recurring attacks of asthma, and the chest may be
gradually deformed, becoming rounded and barrel-shaped, the neck short,
and the shoulders and back bowed. A child of ten or eleven may have the
thoracic conformation of an old man with emphysema.
(c) The Funnel Bh-east (Trichterbrnst) . — This remarkable deformity,
in which there is a deep depression at the lower sternum, has excited much
controversy as to its mode of origin. I believe that in some instances, at
least, it is due to the obstructed breathing in connection with adenoid vegeta-
tions. I have seen two cases in children, in which the condition was in proc-
ess of formation. During inspiration the lower sternum was forcibly re-
tracted, so much so that at the height the depression corresponded to that
of a well-marked " TricMerbrust" While in repose, the lower sternal region
was distinctly excavated.
The voice is altered and acquires a nasal quality. The pronunciation of
certain letters is changed, and there is inability to pronounce the nasal con-
sonants n and m. Bloch lays great stress upon the association of mouth-
breathing with stuttering.
450 DISEASES OF THE DIGESTIVE SYSTEM.
The hearing is impaired, usually owing to the extension of inflammation
along the Eustachian tubes and the obstruction with mucus or the narrowing
of their orifices by pressure of the adenoid vegetations. In some instances it
may be due to retraction of the drums, as the upper pharynx is insufficiently
supplied with air. N'aturally the senses of taste and smell are much impaired.
With these symptoms there may be little or no nasal catarrh or discharge,
but the phar^Tigeal secretion of mucus is always increased. Children, how-
ever, do not notice this, as the mucus is usually swallowed, but older persons
expectorate it with difficidty.
Among other symptoms ma}^ be mentioned headache, which is by no means
imcommon, general listlessness, and an indisposition for physical or mental
exertion. Habit-spasm of the face has been described in connection with it.
I have known several instances in which permanent relief has been afforded
by the removal of the adenoid vegetations. Enuresis is occasionally an asso-
ciated symptom. The influence upon the mental development is striking.
Mouth-breathers are usually dull, stupid, and backward. It is impossible for
them to fix the attention for long at a time, and to this impairment of the
mental function Guye, of Amsterdam, has given the name aprosexia. Head-
aches, forgetfulness, inability to study without discomfort, are frequent symp-
toms of this condition in students. There is more than a grain of truth in
the aphorism shut your mouth and save your life, which is found on the title-
page of Captain Catlin's celebrated pamphlet on mouth-breathing (1861),
to which cause he attributed all the ills of civilization.
A symptom specially associated with enlarged tonsils is fetor of the breath.
In the tonsillar crypts the inspissated secretion undergoes decomposition and
an odor not unlike that of Limburger cheese is produced. The little cheesy
masses may sometimes be squeezed from the crypts of the tonsils. Though
the odor may not apparently be very strong, yet if the mass be squeezed be-
tween the fingers its intensity will at once be appreciated. In some cases of
chronic enlargement the cheesy masses may be deep in the tonsillar crypts;
and if they remain for a prolonged period lime salts are deposited and a
tonsillar calculus is in this way produced.
Children with enlarged tonsils are especially prone to take cold and to
recurring attacks of follicular disease. They are also more liable to diph-
theria, and in them the anginal features in scarlet fever are always more
serious. The ultimate results of untreated adenoid hypertrophy are impor-
tant. In some cases the vegetations disappear, leaving an atrophic condition
of the vault of the phar}Tix. Neglect may also lead to the so-called Thorn-
waldt's disease, in which there is a cystic condition of the pharjTigeal tonsil
and constant secretion of muco-pus.
Dia^osis. — The facial aspect is usually distinctive. Enlarged tonsils are
readily seen on inspection of the pharjmx. There may be no great enlarge-
ment of the tonsils and nothing apparent at the back of the throat even when
the naso-pharynx is completely blocked with adenoid vegetations. In children
the rhinoscopic examination is rarely practicable. Digital examination is the
most satisfactory. The growths can then be felt either as small, flat bodies
or, if extensive, as velvety, grape-like papillomata.
Treatment. — If the tonsils are large and the general state is evidently
influenced by them they should be at once removed. Applications of iodine
DISEASES OF THE (ESOPHAGUS. 451
and iron, or pencilling the crypts with nitrate of silver, are of service in the
milder grades, but it is waste of time to apply them to very enlarged glands.
There is a condition in which the tonsils are not much enlarged, but the crypts
are constantly filled with cheesy secretions and cause a very bad odor in the
breath. In such instances the removal of the secretion and thorough pencil-
ling of the crypts with chromic acid may be practised. The galvano-eautery
is of great service in many cases of enlarged tonsils when there is any objec-
tion to the more radical surgical procedure.
The treatment of the adenoid growths in the pharynx is of the greatest
importance, and should be thoroughly carried out. Parents should be frankly
told that the affection is serious, one which impairs the mental not less than
the bodily development of the child. In spite of the thorough ventilation
of this subject by specialists, practitioners do not appear to have grasped as
yet the full importance of this disease. They are far too apt to temporize and
unnecessarily to postpone radical measures. The child must be anaesthetized,
when the growths can be removed. The dangers of the operation are slight.
Haemorrhage occurs and may be severe. Death from chloroform has been
somewhat frequent. Hinckel (N". Y. Med. Jr., Oct. 29, 1898) has collected
18 cases. They probably come in the category of the cases of sudden death in
lymphatism. The good effects of the operation are often apparent within a
few days, and the child begins to breathe through the nose. In some instances
the habit of mouth-breathing persists. As soon as the child goes to sleep
the lower jaw drops and the air is drawn into the mouth. In these cases a
chin strap can be readily adjusted, which the child may wear at night. In
severe cases it may take months of careful training before the child can speak
properly. An all-important point in the treatment of lesions of the naso-
pharynx (and, indeed, in the prevention of this unfortunate condition) is to
increase the breathing capacity of the chest by making the child perform
systematic exercises, which cause the air to be driven freely and forcibly in
and out through the naso-pharjnix. I can not too strongly commend this
suggestion of Mr. Arbuthnot Lane.
Throughout the entire treatment attention should be paid to hygiene and
diet, and cod-liver oil and the iodide of iron may be administered with benefit.
E. DISEASES OF THE (ESOPHAGUS.
I. ACUTE OESOPHAGITIS.
Etiology. — Acute inflammation occurs (a) in the catarrhal processes of
the specific fevers; more rarely as an extension from catarrh of the pharynx.
(b) As a result of intense mechanical or chemical irritation, produced by
foreign bodies, by very hot liquids, or by strong corrosives, (c) In the form
of pseudo-membranous inflammation in diphtheria, and occasionally in pneu-
monia, typhoid fever, and pysemia. (d) As a pustular inflammation in small-
pox, and, according to Laennec, as a result of a prolonged administration of
tartar emetic, (e) In connection with local disease, particularly cancer either
of the tube itself or extension to it from without. And, lastly, acute oesopha-
gitis, occasionally with ulceration, may occur spontaneously in sucklings.
452 DISEASES OF THE DIGESTIVE SYSTEM.
Morbid Anatomy. — It is extremely rare to see redness of the mucosa,
except when chemical irritants have been swallowed. More commonly the
epithelium is thickened and has desquamated, so that the surface is covered
with a fine granular substance. The mucous follicles are swollen and occa-
sionally there may be seen small erosions. In the pseudo-membranous inflam-
mation there is a grayish croupous exudate, usually limited in extent, at the
upper portion of the gullet. This must not be confounded with the grayish-
white deposit of thrush in children. The pustular disease is very rare in
small-pox. In the plilegmonous inflammation the mucous membrane is greatly
swollen, and there is purulent infiltration in the submucosa. This may be
limited as about a foreign body, or extremely diffuse. It may even extend
throughout a large part of the gullet. Gangrene occasionally supervenes.
There is a remarkable fibrinous or membranous oesophagitis, most- frequently
met with in the fevers, sometimes also in hysteria, in which long casts of the
tube ma}^ be vomited.
Symptoms. — Pain in deglutition is always present in severe inflammation
of the oesophagus. A dull pain beneath the sternum is also present. In the
milder forms of catarrhal inflammation there are usually no symptoms. The
presence of a foreign body is indicated by dysphagia and spasm with the
regurgitation of portions of the food. Later, l3lood and pus may be ejected.
It is surprising how extensive the disease may be in the oesophagus without
producing much pain or great discomfort, except in. swallowing. The intense
inflammation which follows the swallowing of corrosives, when not fatal,
gradually subsides, and often leads to cicatricial contraction and stricture.
Treatment. — The treatment of acute inflammation of the oesophagus is
extremely unsatisfactory, particularly in the severer forms. The slight ca-
tarrhal cases require no special treatment. When the dysphagia is intense
it is best not to give food by the mouth, but to feed entirely by enemata.
Fragments of ice may be given, and as the pain and distress subside, demul-
cent drinks. External applications of cold often give relief.
A chronic form of oesophagitis is described, but this results usually from
the prolonged action of the causes which produce the acute form.
Ulceration, Catarrhal. — Follicular ulcers are not uncommon. Tuberculous
and sj'philitic ulcers are rare. Very prominent varicose veins and small ero-
sions are not uncommon. The other forms are the carcinomatous, the erosion
due to aneurism, and the ulcerative action of corrosive substances. There are
two other important varieties — the ulcers in acute infectious diseases, diph-
theria, scarlet fever, and pneumonia ; and the peptic ulcer of the stomach, first
described by Albers in 1839. Tileston has collected forty cases of peptic
ulcer in the oesophagus. The pain, dysphagia, vomiting, and haemorrhage
have been the most important symptoms. Perforation occurred in six cases,
in one instance into the aorta.
(Esophageal Varices. — Associated with chronic heart-disease and more fre-
quently with the senile and the cirrhotic liver, the oesophageal veins may be-
come distended and varicose. The mucous membrane is in a state of chronic
catarrh, and the patient has frequent eructations of mucus. Eupture of these
varices is one of the commonest causes of hsematemesis in cirrhosis of the
liver and in enlarged spleen. The blood may pass per rectum alone, as in a
case reported by Power, of Baltimore, in 1839.
DISEASES OF THE (ESOPHAGUS. 453
II. SPASM OF THE (ESOPHAGUS (CEsophagismus).
This so-called spasmodic stricture of the gullet is met with in hysterical
patients and hypochondriacs, also in chorea, epilepsy, and especially hydro-
phobia. It is sometimes associated also with the lodgment of foreign bodies.
The idiopathic form is found in females of a marked neurotic habit, but may
also occur in elderly men. It may be present only during pregnancy. Among
the cases which have come under my observation, one was a hypochondriac
over sixty years of age who for many months had taken only liquid food, and
with great difficulty, owing to a spasm which accompanied every attempt to
swallow. The readiness with which the bougie passed and the subsequent
history showed the true nature of the case. The patient complains of inability
to swallow solid food, and in extreme instances even liquids are rejected.
The attack may come on abruptly, and be associated with emotional disturb-
ances and with substernal pain. The bougie, when passed, may be arrested
temporarily at the seat of the spasm, which gradually yields, or it may slip
through without the slightest ejffiort. The condition is rarely serious, though
it may persist for years. Spasm of the lower end of the gullet, associated
with cardio-spasm, may be the cause of a remarkable fusiform dilatation of
the oesophagus. Death has, however, followed it.
The diagnosis is not difficult, particularly in young persons with marked
nervous manifestations. In elderly persons oesophagismus is almost always
connected with hypochondriasis, but great care must be taken to exclude
cancer.
In some cases a cure is at once effected by the passage of a bougie. The
general neurotic condition also requires special attention.
Paralysis of the oesophagus scarcely demands separate consideration. It
is a very rare condition, due most often to central disease, particularly bulbar
paralysis. It may be peripheral in origin, as in diphtheritic paralysis. Occa-
sionally, it occurs also in hysteria. The essential symptom is dysphagia.
III. STRICTURE OF THE CESOPHAGUS.
This results from; (a) Congenital stenosis of the oesophagus. — There are
two groups of cases, one in which there is complete occlusion, and the middle
of the tube is converted into a fibrous cord; the other, the more common, in
which the lower part opens into the trachea or one of the bronchi. There are
some 19 cases on record (William Thomas). (&) The cicatricial contraction
of healed ulcers, usually due to corrosive poisons, occasionally to syphilis, and
in rare instances after the fevers, (c) The growth of tumors in the walls,
as in the so-called cancerous stricture. Eighty-five per cent of the cases are
of this nature (Kelynack and Anderson), (d) External pressure by aneu-
rism, enlarged lymph-glands, enlarged thyroid, other tumors, and sometimes
by pericardial effusion.
The cicatricial stricture may occur anywhere in the gullet, and in ex-
treme cases may, indeed, involve the whole tube, but in a majority of in-
stances it is found either high up near the pharjrnx or low down toward the
stomach. The narrowing may be extreme, so that only small quantities of
454 DISEASES OF THE DIGESTIVE SYSTEM.
food can trickle through, or the obstruction may be quite slight. There is
usually no difficulty in making a diagnosis of the cicatricial stricture, as the
history of mechanical injury or the swallowing of a corrosive fluid makes
clear the nature of the case. When the stricture is low down the oesophagus
is dilated and the walls are usually much hypertrophied. When the obstruc-
tion is high in the gullet, the food is usually rejected at once, whereas, if it is
low, it may be retained and a considerable quantity collects before it is re-
gurgitated. Any doubt as to its having reached the stomach is removed by
the alkalinity of the material ejected and the absence of the characteristic
gastric odor. Auscultation of the oesophagus may be practised and is some-
times of service. The patient takes a mouthful of water and the auscultator
listens along the left of the spine. The normal oesophageal hruit may be
heard later than seven seconds, the normal time, or there may be heard a loud
splashing, gurgling sound. The secondary murmur, heard as the fluid enters
the stomach, may be absent. The passage of the oesophageal bougie will deter-
mine more accurately the locality. Conical bougies attached to a flexible
whalebone stem are the most satisfactory, but the gum-elastic stomach tube
may be used; a large one should be tried first. The patient should be placed
on a low chair with the head well thrown back. The index finger of the
left hand is passed far into the pharynx, and in some instances this procedure
alone may determine the presence of a new growth. The bougie is passed
beside the finger until it touches the posterior wall of the pharynx, then along
it, more to one side than in the middle line, and so gradually pushed into
the gullet. It is to be borne in mind that in passing the cricoid cartilage there
is often a slight obstruction. Great gentleness should be used, as it has hap-
pened more than once that the bougie has been passed through a cancerous
ulcer into the mediastinum or through a diverticulum. I have known this
accident to happen several times — once in the case of a distinguished surgeon,
who performed oesophagotomy and passed the tube, as he thought, into the
stomach. The post mortem on the next day showed that the tube had entered
a diverticulum and through it the left pleura, in which the milk injected
through the tube was found. In another instance the tube passed through a
cancerous ulcer into the lung, which was adherent and inflamed. In a recent
instance the passage of the tube was the cause of an acute pleurisy. Fortu-
nately these accidents^ sometimes unavoidable, are extremely rare. It is well
always, as a precautionary measure before passing the bougie, to examine
carefully for aneurism, which may produce all the symptoms of organic stric-
ture. In cases in which the narrowing is extreme there is always emaciation.
For treatment, surgical works must be consulted.
IV. CANCER OF THE CESOPHAGXJS.
This is usually epithelioma. It is not a common disease; there have been
only 20 cases in the medical wards of the Johns Hopkins Hospital in sixteen
years. It may occur in quite young persons; I saw a case with Julius Fried-
enwald in a woman under thirty years of age. It is more frequent in males
than in females. The middle and lower thirds are most often affected. At
first confined to the mucous membrane, the cancer gradually increases and
soon "ulcerates. The lumen of the tube is narrowed, but when ulceration is
DISEASES OF THE (ESOPHAGUS. 455
extensive in the later stages the stricture may be less marked. Dilatation of
the tube and hypertrophy of the walls usually take place above the cancer.
The ulcer may perforate the trachea or a bronchus, the lung, the pleura, the
mediastinum, the aorta or one of its larger branches, the pericardium, or it
may erode the vertebral column. The recurrent laryngeal nerves are not
infrequently implicated. Perforation of the lung produces, as a rule, local
gangrene.
Symptoms. — The earliest symptom is dysphagia, which is progressive' and
may become extreme, so that the patient emaciates rapidly. Regurgitation
may take place at once; or, if the cancer is situated near the stomach, it may
be deferred for ten or fifteen minutes, or even longer if the tube is much
dilated. The rejected materials may be mixed with blood and may contain
cancerous fragments. In persons over fifty years of age persistent difficulty
in swallowing accompanied by rapid emaciation usually indicates oesophageal
cancer. The cervical lymph-glands are frequently enlarged and may give
early indication of the nature of the trouble. Pain may be persistent or be
present only when food is taken. In certain instances the pain is very great.
The latent cases are very rare. Bronchitis and broncho-pneumonia are com-
mon terminal events.
Prognosis. — The prognosis is hopeless; the patients usually become pro-
gressively emaciated, and die either of asthenia or sudden perforation of the
ulcer.
Diagnosis. — In the diagnosis of the condition it is important, in the first
place, to exclude pressure from without, as by aneurism or other tumor. The
history enables us to exclude cicatricial stricture and foreign bodies. The
sound may be passed and the presence of the stricture determined. As men-
tioned above, great care should be exercised. Fragments of carcinomatous
tissue may in some instances be removed with the tube.' On auscultation
along the left side of the spine the primary oesophageal murmur may be much
altered in quality.
Treatment. — In most cases milk and liquids can be swallowed, but supple-
mentary nourishment should be given by the rectum. It may be advisable
in some instances to pass a tube into the stomach and introduce food in this
way. When there is difficulty in feeding the patient it is very much better
to have gastrostomy performed at once, as it gives the greatest comfort and
ease, and prolongs the patient's life.
V. RUPTURE OF THE CESOPHAGUS.
(1) Rupture may occur in a healthy organ as a result of prolonged vomit-
ing after a full meal, or when intoxicated. Eight cases are on record (Vir-
chow's Archiv, vol. 162). Boerhaave described the first case in Baron Wassen-
nar, who " broke asunder the tube of the oesophagus near the diaphragm, so
that, after the most excruciating pain, the elements which he swallowed passed,
together with the air, into the cavity of the thorax, and he expired in twenty-
four hours."
(2) In a few cases the rupture has occurred in a diseased and weakened
tube, near the scar of an ulcer, for example.
(3) Post-mortem softening — oesophago-malacia — a not very uncommon
456 DISEASES OF THE DIGESTIVE SYSTEM.
condition, must not be mistaken for it. In spontaneous rupture the rent
is clean-cut and circumferential; in malacia it is rounded and often cribri-
form^ and the margins are softened. The contents of the stomach may be
in the left pleura.
VI. DILATATIONS AND DIVERTICULA.
Stenosis of the gullet is followed by secondary dilatation of the tube above
the constriction and great hypertrophy of the walls. Primary dilatation,
which is extremel}^ rare, appears to be associated with spasm of the lower
end of the gullet and of the cardiac orifice. The tube may attain extraor-
dinary dimensions, as in the specimen presented in 1904 to the Association
of American Physicians by Kinnicutt (see Transactions). Eegurgitation of
food is the most common symptom. There may also be difficulty in breathing
from pressure.
Diverticula are of two forms: (a) Pressure diverticula, which are most
common at the junction of the pharynx and gullet, on the posterior wall.
Owing to weakness of the muscles at this spot, local bulging occurs, which is
gradually increased by the pressure of food, and finally forms a saccular
pouch. (&) The traction diverticula situated on the anterior wall near the
bifurcation of the trachea, result, as a rule, from the extension of inflam-
mation from the lymph-glands with adhesion and subsequent cicatricial con-
traction, by which the wall of the gullet is drawn out. Diverticula have been
successfully extirpated.
A rare and remarkable condition, of which a case has been recorded by
MacLachlan, and of which a second is still (1904) in attendance at my clinic,
is the cesophago-pleuro-cutaneous fistula. In my patient fluids are discharged
at intervals through a fistula in the right infra-clavicular region, which
appears to communicate with a cavity in the upper part of the pleura or
lung. The condition has persisted for more than twenty-five years.
F. DISEASES OE THE STOMACH.
I. ACUTE GASTRITIS.
(Simple Gastritis ; Acute Gastric Catarrh ; Acute Dyspepsia.)
Etiology. — Acute gastric catarrh, one of the most common of complaints,
occurs at all ages, and is usually traceable to errors in diet. It may follow
the ingestion of more food than the stomach can digest, or it may result from
taking unsuitable articles, which either themselves irritate the mucosa or,
remaining undigested, decompose, and so excite an acute dyspepsia. A fre-
quent cause is the taking of food which has begun to decompose, particularly
in hot weather. In children these fermentative processes are very apt to
excite acute catarrh of the bowels as well. Another very common cause is the
abuse of alcohol, and the acute gastritis which follows a drinking-bout is
one of the most typical forms of the disease. The tendency to acute indi-
gestion varies very much in difEerent individuals, and indeed in families.
DISEASES OF THE STOMACH. 457
We recognize this in using the expressions a " delicate stomach " and a
" strong stomach." Gouty persons are generally thought to be more disposed
to acute dyspepsia than others. Acute catarrh of the stomach occurs at the
outset of many of the infectious fevers.
Lebert described a special infectious form of gastric catarrh, occurring
in epidemic form, and only to be distinguished from mild typhoid fever by
the absence of rose spots and swelling of the spleen. Many practitioners still
adhere to the belief that there is a form of gastric fever, but the evidence
of its existence is by no means satisfactory, and certainly a great majority
of all cases are examples of mild typhoid.
Morbid Anatomy. — Beaumont's study of St. Martin's stomach showed
that in acute catarrh the mucous membrane is reddened and swollen, less
gastric juice is secreted, and mucus covers the surface. Slight haemorrhages
may occur or even small erosions. The submucosa may be somewhat oedema-
tous. Microscopically the changes are chiefly noticeable in the mucous and
peptic cells, which are swollen and more granular, and there is an infiltration
of the intertubular tissue with leucocytes.
Symptoms. — In mild cases the symptoms are those of slight " indigestion "
— an uncomfortable feeling in the abdomen, headache, depression, nausea,
eructations, and vomiting, which usually gives relief. The tongue is heavily
coated and the saliva is increased. In children there are intestinal symptoms
— diarrhoea and colicky pains. There is usually no fever. The duration is
rarely more than twenty-four hours. In the severer forms the attack may
set in with a chill and febrile reaction, in which the temperature rises to
103° or 103°. The tongue is furred, the breath heavy, and vomiting is fre-
quent. The ejected substances, at first mixed with food, subsequently con-
tain much mucus and bile-stained fluids. There may be constipation, but
very often there is diarrhoea. The urine presents the usual febrile charac-
teristics, and there is a heavy deposit of urates. The abdomen may be some-
what distended and slightly tender in the epigastric region. Herpes may
appear on the lips. The attack may last from one to three days, and occa-
sionally longer. The examination of the vomitus shows, as a rule, absence
of the hydrochloric acid, presence of lactic and fatty acids, and marked
increase in the mucus.
Diagnosis. — The ordinary afebrile gastric catarrh is readily recognized.
The acute febrile form is so similar to the initial symptoms of many of the
infectious diseases that it is impossible for a day or two to make a diagnosis,
particularly in the cases which have come on, so to speak, spontaneously and
independently of an error in diet. Some of these resemble closely an acute
infection; the symptoms may be very intense, and if, as sometimes happens,
the attack sets in with severe headache and delirium the case may be mistaken
for meningitis. When the abdominal pains are intense the attack may be
confounded with gallstone colic. In discriminating between acute febrile gas-
tritis and the abortive forms of typhoid fever it is to be borne in mind that
in the former the temperature rises abruptly, the remissions are slighter, and
the drop is more sudden. The initial bronchitis, the well-marked splenic
enlargement, and the rose spots are not present. It is a very common error
to class under gastric fever the mild forms of the various infectious disorders.
The gastric crises in locomotor ataxia have in many instances been confounded
458 DISEASES OF THE DIGESTIVE SYSTEM.
with a simple acute gastritis, and it is always wise in adults to test the knee-
jerks and pupillary reactions.
Treatment. — Mild cases recover spontaneously in twenty-four hours, and
require no treatment other than a dose of castor oil in children or of blue
mass in adults. In the severer forms, if there is much distress in the region
of the stomach, the vomiting should be promoted b}^ warm water or the simple
emetics. A full dose of calomel, 8 to 10 grains, should be given, and followed
the next morning by a dose of Hunyadi-Janos or Carlsbad water. If there
is eructation of acid fluid, bicarbonate of soda and bismuth may be given.
The stomach should have, if possible, absolute rest, and it is a good plan in
the case of strong persons, particularly in those addicted to alcohol, to cut
off all food for a day or two. The patient may be allowed soda water and
ice freely. It is well not to attempt to check the vomiting unless it is
excessive and protracted. Eecovery is usually complete, though repeated
attacks may lead to subacute gastritis or to the establishment of chronic
dyspepsia.
Phleg-monoTis Gastritis; Acute Suppurative Gastritis. — This is an ex-
cessively rare disease, characterized by the occurrence of suppurative processes
in the sub mucosa. The affection is more common in men than in women.
Leith has collected 85 cases, and has given the best account in the literature
(Edinburgh Hospital Reports, vol. iv). The cause is seldom obvious. It
has been met with as an idiopathic affection, but it has occurred also in
puerperal fever and other septic processes, and has occasionally followed
trauma. Anatomically there appear to be two forms, a diffuse purulent
infiltration and a localized abscess formation, in which case the tumor may
reach the size of an egg, and may burst into the stomach or into the peri-
toneal cavity. In two of the cases I have seen, the abscess was in connection
with cancer of the stomach, and it is interesting to note that in both there
were recurring chills. In a third case, in a diffuse carcinoma, there was ex-
tensive phlegmonous inflammation with vomiting of a horribly foetid material.
Symptoms. — The symptoms are variable. There are usually pain in the
abdomen, fever, dry tongue, and symptoms of a severe infective process, de-
lirium and coma preceding death. Jaundice has been met with, and a pur-
puric rash. Occasionally, when the abscess tumor is large, it has been felt
externally, in one case forming a mass as large as two fists. There are in-
stances which run a more chronic course, with pains in the abdomen, fever,
and chills.
Diagnosis. — The diagnosis is rarely possible, even when with abscess rup-
ture occurs, and the pus is vomited, as it is not possible to differentiate the
condition from an abscess perforating into the stomach from without. It is
stated, however, that Chvostek made the diagnosis in one of his cases.
Toxic Gastritis. — This most intense form of inflammation of the stomach
is excited by the swallowing of concentrated mineral acids or strong alkalies,
or by such poisons as phosphorus, corrosive sublimate, ammonia, arsenic, etc.
In the non-corrosive poisons, such as phosphorus, arsenic, and antimony, the
process consists of an acute degeneration of the glandular elements, and haem-
orrhage. In the powerful concentrated poisons the mucous membrane is exten-
sively destroyed, and may be converted into a brownish-black eschar. In
the less severe grades there may be areas of necrosis surrounded by inflam-
DISEASES OF THE STOMACH. 459
matory reaction, while the submucosa is hsemorrhagic and infiltrated. The
process is of course more intense at the fundus, but the active peristalsis may
drive the poison through the pylorus into the intestine.
Symptoms. — Tlie symptoms are intense pain in the mouth, throat, and
stomach, salivation, great difficulty in swallowing, and constant vomiting, the
vomited materials being bloody and sometimes containing portions of the
mucous membrane. The abdomen is tender, distended, and painful on pres-
sure. In the most acute cases symptoms of collapse supervene; the pulse is
weak, the skin pale and covered with sweat; there is restlessness, and some-
times convulsions. There may be albumin or blood in the urine, and petechise
may occur on the skin. When the poison is less intense, the sloughs may
separate, leaving ulcers, which too often lead, in the oesophagus to stricture,
in the stomach to chronic atrophy, and finally to death from exhaustion.
Diagnosis. — The diagnosis of toxic gastritis is usually easy, as inspection
of the mouth and pharynx shows, in man}^ instances, corrosive effects, while
the examination of the vomit may indicate the nature of the poison.
In poisoning by acids, magnesia should be administered in milk or with
egg albumen. When strong alkalies have been taken, the dilute acids should
be administered. If the case is seen early, lavage should be used. For the
severe inflammation which follows the swallowing of the stronger poisons
palliative treatment is alone available, and morphia may be freely employed
to allay the pain.
Diphtheritic or Membranous Gastritis. — This condition is met with occa-
sionally in diphtheria, but more commonly as a secondary process in typhus
or typhoid fever, pneumonia, pyaemia, small-pox, and occasionally in debili-
tated children. The exudation may be extensive and uniform or in patches.
The condition is not recognizable during life, unless, as in a case of John
Thomson's, the membranes are vomited.
Mycotic and Parasitic Gastritis. — It occasionally happens that fungi grow
in the stomach and excite inflammation. One of the most remarkable cases
of the kind is that reported by Kundrat, in which the favus fungus occurred
in the stomach and intestine.
In cancer and in dilatation of the stomach the sarcin^ and yeast fungi
probably aid in maintaining the chronic gastritis. As a rule, the gastric
juice is capable of killing the ordinary bacteria. Orth states that the anthrax
bacilli, in certain cases, produce swelling of the mucosa and ulceration.
Eug. Fraenkel has reported a case of acute emphysematous gastritis probably
of mycotic origin. The larvae, of certain insects may excite gastritis, as in the
cases reported by Gerhardt, Meschede, and others. In rare instances tuber-
culosis and syphilis attack the gastric mucosa.
II. CHRONIC GASTRITIS.
(Chronic Catarrh of the Stomach ; Chronic Dyspepsia.)
Definition. — A condition of disturbed digestion associated with increased
mucous formation, qualitative or quantitative changes in the gastric juice,
enfeeblement of the muscular coats, so that the food is retained for an ab-
normal time in the stomach; and, finally, with alterations in the structure
of the mucosa.
460 DISEASES OF THE DIGESTIVE SYSTEM.
Etiology. — The causes of chronic gastritis may be classified as follows:
(1) Dietetic. Unsuitable or improperly prepared, food, and the persistent
use of certain articles of diet, such as very fat substances or foods containing
too much of the carbohydrates. The use in excessive quantit}^ of hot bread,
hot cakes, and pie is a fruitful cause, particular!}- in the United States. The
use in excess of tea or coffee, and, above all, of alcohol in its various forms.
Under this heading, too, may be mentioned the habits of eating at irregular
hours or too rapidly and imperfectly chewing the food. Excess in eating
does more damage than excess in drinking. The platter kills more than the
sword. A common cause of chronic catarrh is drinking too freely of ice-
water during meals, a practice which plays no small part in the prevalence
of dyspepsia in America. Another frequent cause is the abuse of tobacco,
particularly chewing. (2) Constitutional causes. Ana?mia, chlorosis, chronic
tuberculosis, gout, diabetes, and Bright's disease are often associated with
chronic gastric catarrh. (3) Local conditions: (a) of the stomach, as in
cancer, ulcer, and dilatation, which are invariably accompanied by catarrh;
(&) conditions of the portal circulation, causing chronic engorgement of the
mucous membrane, as in cirrhosis, chronic heart-disease, and certain chronic
lung affections.
Morbid Anatomy. — Anatomically two forms of chronic gastritis may be
recognized, the simple and the sclerotic.
(a) Simple Chroxic Gastritis. — The organ is usually enlarged, the
mucous membrane pale gray in color, and covered with closely adherent,
tenacious mucus. The veins are large, patches of ecchymosis are not infre-
quently seen, and in the chronic catarrh of portal obstruction and of chronic
heart-disease small hgemorrhagic erosions. Toward the pylorus the mucosa
is not infrequently irregularly pigmented, and presents a rough, wrinkled,
mammillated surface, the etat mamelone of the French, a condition which
may sometimes be so prominent that writers have described it as gastritis
polyposa. The membrane may be thinner than normal, and much firmer,
tearing less readily with the finger-nail. Ewald thus describes the histolog-
ical changes: The minute anatomy shows the picture of a parenchymatous
and an interstitial inflammation. The gland cells are in part eroded or show
cloudy granular swelling or atrophy. The distinction between the principal
and marginal cells can not be recognized, and in many places, particularly in
the pyloric region, the tubes have lost their regular form and show in many
places an atypical branching, like the fingers of a glove. Individual glands
are cut off toward the fundus, but appear at the border of the submucosa as
cysts, partly empty, with a smooth membrane, partly filled with remnants
of hyaline and retractile epithelium. An abundant small-celled infiltration
presses apart the tubules, being particularly marked toward the surface of
the mucosa, and from the submucosa extensions of the connective tissue may
be seen passing between the glands. The mucoid transformation of the cells
of the tubules is a striking feature in the process and may extend to the
very fundus of the glands.
(&) Sclerotic Gastritis. — As a final result of the parench}Tnatous and
interstitial changes the mucous membrane may undergo complete atrophy,
so that but few traces of secreting substance remain. There appear to be
two forms of this sclerotic atrophy — one with thiiming of the coats of the
DISEASES OF THE STOMACH. 461
stomachy phthisis ventriculi, and a retention or even increase of the size of
the organ; the other with enormous thickening of the coats and great reduc-
tion in the volume of the organ, the condition which is usually described as
cirrJwsis ventriculi. Extreme atrophy of the mucous membrane of the stom-
ach has been carefully studied by Fenwick, Ewald, and others, and we now
recognize the fact that there may be such destruction and degeneration of the
glandular elements by a progressive growth of interstitial tissue that ulti-
mately scarcely a trace of secreting tissue remains. In a characteristic dase,
studied by Henry and myself, the greater portion of the lining membrane
of the stomach was converted into a perfectly smooth, cuticular structure,
showing no trace whatever of glandular elements, with enormous hypertrophy
of the muscularis mucosaB, and here and there formation of cysts. In the
other form, with identical atrophy and cyst formation, there is enormous
increase in the connective tissue, and the stomach may be so contracted that
it does not hold more than a couple of ounces. The walls may measure from
2 to 3 cm.; the greatest increase in thickness is in the submucosa, but the
hypertrophy also extends to the muscular layers. A similar affection may
coexist in the caecum and colon. The condition may be difficult to distinguish
from diffuse carcinoma. There may be also proliferative peritonitis, with
perihepatitis, perisplenitis, and ascites. While one is not justified in saying
that all cases of cirrhosis of the stomach represent a final stage in the history
of a chronic catarrh, it is true that in most cases the process is associated
with atrophy of the gastric mucosa, while the history indicates the existence
of chronic dyspepsia.
Symptoms. — The affection persists for an indefinite period, and, as is the
case with most chronic diseases, changes from time to time. The appetite
is variable, sometimes greatly impaired, at others very good. Among early
symptoms are feelings of distress or oppression after eating, which may be-
come aggravated and amount to actual pain. When the stomach is empty
there may also be a painful feeling. The pain differs in different cases, and
may be trifling or of extreme severity. When localized and felt beneath the
sternum or in the precordial region it is known as heart-burn or sometimes
cardialgia. There is pain on pressure over the stomach, usually diffuse and
not severe. The tongue is coated, and the patient complains of a bad taste in
the mouth. The tip and margin of the tongue are very often red. Associated
with this catarrhal stomatitis there may be an increase in the salivary and
pharyngeal secretions. Nausea is an early symptom, and is particularly apt
to occur in the morning hours. It is not, however, nearly so constant a symp-
tom in chronic gastritis as in cancer of the stomach, and in mild grades of the
affection it may not occur at all. Eructation of gas, which may continue for
some hours after taking food, is a very prominent feature in cases of so-called
flatulent dyspepsia, and there may be marked distention of the intestines.
With the gas, bitter fluids may be brought up. Vomiting, which is not very
frequent, occurs either immediately after eating or an hour or two later.
In the chronic catarrh of old topers a bout of morning vomiting is common,
in which a slimy mucus is brought up. The vomitus consists of food in
various stages of digestion and slimy mucus, and the chemical examination
shows the presence of abnormal acids, such as butyric, or even acetic, in
addition to lactic acid, while the hydrochloric acid, if indeed it be present.
462 DISEASES OF THE DIGESTIVE SYSTEM.
is ranch reduced in quantity. The digestion may be much delayed, and on
washing out the stomach as late as seven hours after eating, portions of food
are still present. The prolonged retention favors decomposition, the stomach
becomes distended with gas, and this, with the chronic catarrh, may induce
gradually an atony of the muscular walls. The absorption is slow, and
iodide of potassium, given in capsules, which should normally reach the saliva
within fifteen minutes, may not be evident for more than half an hour.
Constipation is usually present, but in some instances there is diarrhoea,
and undigested food passes rapidly through the bowels. The urine is often
scanty, high-colored, and deposits a heavy sediment of urates.
Of other symptoms headache is common, and the patient feels constantly
out of sorts, indisposed for exertion, and low-spirited. In aggravated cases
melancholia may occur. Trousseau called attention to the occurrence of
vertigo, a marked feature in certain cases. The j)ulse is small, sometimes
slow, and there may be palpitation of the heart. Fever does not occur.
Cough is sometimes present, but the so-called stomach cough of chronic
dyspeptics is in all probability' dependent upon pharvngeal irritation.
The Gastric Contents. — The fasting stomach may be empty or it may
contain much mucus — gastritis mucipara of Boas. In the test breakfast,
withdrawn in an hour, the HCl is usually diminished, though it may be nor-
mal— gastritis acida. In other cases the free HCl may be absent — gastritis
anacida. While in the advanced forms of atrophy of the mucosa there may
be neither acids nor ferments — gastritis atrophicans.
The motor function of the stomach is not usually much impaired.
The s}Tnptoms of atrophy of the mucous membrane of the stomach, with
or without contraction of the organ, are very complex, and can not be said
to present a uniform picture. The majority of the cases present the S}Tnp-
toms of an aggravated chronic dyspepsia, often of suc"h severity that cancer
is suspected. In one of the cases which I examined, the persistent distress
after eating, the vomiting, and the gradual loss of flesh and strength, very
naturally led to this diagnosis, but the duration of the disease far exceeded
that of ordinary carcinoma. In the cirrhotic form the tumor mass may some-
times be felt. In atrophy of the stomach, whether associated with cirrhosis
or not, the clinical picture may be that of a severe anaemia. As early as
1860, Flint called attention to this connection between atrophy of the gastric
tubules and anaemia, an observation which Fenwick and others have amply
confirmed.
Diagnosis. — Ewald distinguishes three forms of chronic gastritis: (1)
Simple gastritis ; (2) mucous (sclileimige) gastritis; (3) atrophic gastritis.
In (1) the fasting stomach contains only a small quantity of a slimy
fluid, while after the test breakfast the HCl is diminished in quantity or
may be absent. Lactic acid and the fatty acids may be present. After Boas's
more rigid test meal the organic acids are rarely found. The pepsin and
rennet are always present.
In (2) the acidit}' is always slight and the condition is distinguished from
(1) chiefly by the large amount of mucus present.
In (3) the fasting stomach is generally empty, while after the test break-
fast HCl, pepsin, and the curdling ferment are wholly wanting.
The diagnosis of cancer of the stomach from chronic gastritis may be very
DISEASES OF THE STOMACH. 463
difficult when a tumor is not present. The cases require most careful study,
and it may take several months before a decision can be reached.
Treatment. — When possible the cause in each case should be ascertained
and an attempt made to determine the special form of indigestion. Usually
there is no difficulty in differentiating the ordinary catarrhal and the nervous
varieties, A careful study of the phenomena of digestion in the way already
laid down, though not essential in every instance, should certainly be carried
out in the more obstinate and obscure forms. Two important questions should
be asked of every dyspeptic — first, as to- the time taken at his meals; and,
second, as to the quantity he eats. Practically a large majority of all cases
of disturbed digestion come from hasty and imperfect mastication of the food
and from overeating. Especial stress should be laid upon the former point.
In some instances it will alone suffice to cure dyspepsia if the patient will
count a certain nmnber before swallowing each mouthful. The second point
is of even greater importance. People habitually eat too much, and it is
probably true that a greater number of maladies arise from excess in eating
than from excess in drinking. Chittenden's researches have shown that we
require much less nitrogenous food to maintain a standard of perfect health
— a lesson that the Hindoos and Japanese have also taught us. George
Cheyne's thirteenth aphorism contains a volume of dietetic wisdom : " Every
wise man, after Fifty, ought to begin to lessen at least the quantity of his
Aliment, and if he would continue free of great and dangerous Distempers
and preserve his Senses and Faculties clear to the last he ought every seven
years go on abateing gradually and sensibly, and at last descend out of Life
as he ascended into it, even into the Child's Diet."
(a) General and Dietetic. — A careful and systematically arjanged diet-
ary is the first, sometimes the only, essential in the treatment of a case of
chronic dyspepsia. It is impossible to lay down rules applicable to all cases.
Individuals differ extraordinarily in their capability of digesting different
articles of food, and there is much truth in the old adage, " One man's food
is another man's poison." The individual preferences for different articles
of food should be permitted in the milder forms. Physicians have probably
been too arbitrary in this direction, and have not yielded sufficiently to the
intimations given by the appetite and desires of the patient.
A rigid milk diet may be tried. " Milk and sweet sound Blood differ in
nothing but in Color: MilTc is Blood" (George Che3me). In the forms asso-
ciated with Bright's disease and chronic portal congestion, as well as in many
instances in which the d3^spepsia is part of a neurasthenic or hysterical trouble,
this plan in conjunction with rest is most efficacious. If milk is not digested
well it may be diluted one-third with soda water or Vichy, or 5 to 10 grains
of carbonate of soda, or a pinch of salt may be added to each tumblerful. In
many cases the milk from which the cream has been taken is better borne.
Buttermilk is particularly suitable, but can rarely be taken for so long a time
alone, as patients tire of it much more readily than they do of ordinary milk.
ISTot only can the general nutrition be maintained on this diet, but patients
sometimes increase in weight, and the unpleasant gastric symptoms disappear
entirely. It should be given at fixed hours and in definite quantities. A pa-
tient may take 6 or 8 ounces every three hours. The amount necessary varies
a good deal, but at least 3 to 5 pints should be given in the twenty-four hours.
464 DISEASES OF THE DIGESTIVE SYSTEM.
This form of diet is not, as a rule, well borne when there is a tendency to
dilatation of the stomach. The milk may be previously peptonized, Imt it is
impossible to feed a chronic dyspeptic in this way. The stools should be
carefully watched, and if more milk is taken than can be digested it is well
to supplement the diet with eggs and dry toast or biscuits.
In a large proportion of the cases of chronic indigestion it is not necessary
to annoy the patient with such strict dietaries. It may be quite sufficient to
cut off certain articles of food. Thus, if there are acid eructations or flatu-
lency, the farinaceous foods should be restricted, particularly potatoes and
the coarser vegetables. A fruitful source of indigestion is the hot bread which,
in different forms, is regarded as an essential part of an American breakfast.
This, as well as the various forms of pancakes, pies and tarts, with heavy
pastry, and fried articles of all sorts, should be strictly forbidden. As a rule,
white bread, toasted, is more readily digested than bread made from the whole
meal. Persons, however, differ very much in this respect, and the Graham
or brown bread is for many people most digestible. Sugar and very sweet
articles of food should be taken in great moderation or avoided altogether
by persons with chronic dyspepsia. Many instances of aggravated indigestion
have come to my notice due to the prevalent practice of eating largely of
ice-cream. One of the most powerful enemies of the American stomach in
the present day is the soda-water fountain, which has usurped so important
a place in the apothecary shop.
Fats, with the exception of a moderate amount of good butter, very fat
meats, and thick, greasy soups should be avoided. Ripe fruit in moderation
is often advantageous, particularly when cooked. Bananas are not, as a rule,
well borne. ■ Strawberries are to many persons a cause of an annual attack of
indigestion and sore throat in the spring months.
As stated, in the matter of special articles of food it is impossible to lay
do"v\Ti rigid rules, and it is the common experience that one patient with
indigestion will take with impunity the very articles which cause the greatest
distress to another.
Another detail of importance which may be mentioned in this connection
is the general hygienic management of dyspeptics. These patients are often
introspective, dwelling in a morbid manner on their symptoms, and much
inclined to take a despondent view of their condition. Very little progress
can be made unless the physician gains their confidence from the outset.
Their fears and whims should not be made too light of or ridiculed. Sys-
tematic exercise, carefully regulated, particularly when, as at watering places,
it is combined with a restricted diet, is of special service. Change of air and
occupation, a prolonged sea voyage, or a summer in the mountains will some-
times cure the most obstinate dyspepsia.
(&) Medicinal. — The special therapeutic measures may be divided into
those which attempt to replace in the digestive juices important elements
which are lacking and those which stimulate the weakened action of the organ.
In the first group come the hydrochloric acid and ferments, which are so
freely employed in dyspepsia. The former is the most important. It is the
ingredient in the gastric juice most commonly deficient. It is not only neces-
sary for its own important actions, but its presence is intimately associated
with that of the pepsin, as it is only in the presence of a sufficient quantity
DISEASES OF THE STOMACH. 465
that the pepsinogen is converted into the active digestive ferment. It is best
given. as the dilute acid taken in somewhat larger quantities than are usually
advised. Ewald recommends large doses — of from 90 to 100 drops — at in-
tervals of fifteen minutes after the meals. Leube and Kiegel advise smaller
doses. Probably from 15 to 20 drops is sufficient. The prolonged use of it
does not appear to be in any way hurtful. The use, however, should be re-
stricted to cases of neurosis and atrophy of the mucous membrane. In actual
gastritis its value is doubtful.
Nitrate of silver is a good remedy in some cases, used in solution in the
lavage (1 to 1,500 or 1 to 2,000), or in pill form, one-eighth to one- fourth
of a grain three times a day. For many years Pepper advocated the more
extended use of this drug in chronic gastritis. I have seen an instance of
argyria after its protracted use.
The digestive ferments : These are extensively employed to strengthen the
weakened gastric and intestinal secretions. The use of pepsin, according to
Ewald, may be limited to the cases of advanced mucous catarrh and the in-
stances of atrophy of the stomach, in which it should be given, in doses of
from 10 to 15 grains, with dilute hydrochloric acid a quarter of an hour after
meals. It may be used in various different forms, either as a powder or in
solution or given with the acid. The powder is much more certain.
Pancreatin is of equal or even greater value than the pepsin. Pains
should be taken to use a good article, such as that prepared by Merck. It
should be given in doses of from 15 to 20 grains, in combination with bicar-
bonate of soda. It is conveniently administered in tablets, each of which
contains 5 grains of the pancreatin and the soda, and of these two or three
may be taken fifteen or twenty minutes after each meal. Ptyalin and diastase
are particularly indicated when the acid is excessive. The action of the
former continues in the stomach during normal digestion. The malt diastase
is often very serviceable given with alkalies.
Of measures which stimulate the glandular activity in chronic dyspepsia
lavage is by far the most important, particularly in the forms characterizied
by the secretion of a large quantity of mucus. Lukewarm water should be
used, or, if there is much mucus, a 1-per-cent salt solution, or a S- to 5-per-
cent solution of bicarbonate of soda. If there is much fermentation the
3-per-cent solution of boric acid may be used, or a dilute solution of carbolic
acid. It is best employed in the morning on an empty stomach, or in the
evening some hours after the last meal. It is perhaps preferable in the morn-
ing, except in those cases in which there is much nocturnal distress and flatu-
lency. Once a day is, as a rule, sufficient, or, in the ease of delicate persons,
every second day. The irrigation may be continued until the water which
comes away is quite clear. It is not necessary to remove all the fluid after
the irrigation.
While perhaps in some hands this measure has been carried to extremes,
it is one of such extraordinary value in certain cases that it should be more
widely employed by practitioners. When there is an insuperable objection to
lavage a substitute may be used in the form of warm alkaline drinks, taken
slowly in the early morning or the last thing at night.
Of medicines which stimulate the gastric secretion the most important are
the bitter tonics, such as quassia, gentian, calumba, cundurango, ipecacuanha,
81
466 DISEASES OF THE DIGESTIVE SYSTEM.
strychnia, and cardamoms. These are probably of more value in chronic gas-
tritis than the hydrochloric acid. Of these stryclmia is the most powerful,
though none of them have probably any very great stimulating action on the
secretion, and influence rather the appetite than the digestion. Of stomachics
which are believed to favorably influence digestion the most important are
alcohol and common salt. The former would appear to act in moderate quan-
tities by increasing the acid in the gastric juice, and with it probably the
pepsin formation. Others hold that it is not so much the secretory as the
motor function of the stomach which the alcohol stimulates. In moderate
quantities it has certainly no directly injurious influence on the digestive
processes. Special care should be taken, however, in ordering alcohol to dys-
peptics. If a patient has been in the habit of taking beer or light wines or
stimulants with his meals, the practice may be continued if moderate quanti-
ties are taken. Beer, as a rule, is not well borne. A dry sherry or a glass
of claret is preferable. In the case of women with any form of dyspepsia
stimulants should be employed with the greatest caution, and the practitioner
should know his patient well before ordering alcohol.
The importance of salt in gastric digestion rests upon the fact that its
presence is essential in the formation of the hydrochloric acid. An increase
in its use may be advised in all cases of chronic dyspepsia in which the acid
is defective.
Treatment of Special Conditions. — Fermentation and Flatulency. — When
the digestion is slow or imperfect, fermentation goes on in the contents, with
the formation of gas and the production of lactic, butyric, and acetic acids.
For the treatment of this condition careful dieting may suffice, particularly
forbidding such articles as tea, pastry, and the coarser vegetables. It is usually
combined with pyrosis, in which the acid fluids are brought into the mouth.
Bismuth and carbonate of soda sometimes suffice to relieve the condition.
Thymol, creasote, and carbolic acid may be employed. For acid dyspepsia
Sir William Eoberts recommends the bismuth lozenge of the British Pharma-
copoeia, the antacid properties of which depend on chalk and bicarbonate of
soda. It should be taken an hour or two after meals, and only when the pain
and uneasiness are present. The burnt magnesia is also a good remedy.
Grlycerin in from 20- to 60-minim doses, the essential oils, animal charcoal
alone or in combination with compound cinnamon powder, may be tried.
If there is much pain, chloroform in 20-minim doses or a teaspoonful
of Hoffman's anodyne may be used. In obstinate cases lavage is
indicated and is sometimes striking in its effects. Alkaline solutions may
be used.
Vomiting is not a feature which often calls for treatment in chronic dys-
pepsia; sometimes in children it is a persistent symptom. Creasote and
carbolic acid in drop doses, a few drops of chloroform or of dilute hydro-
cyanic acid, cocaine, bismuth, and oxalate of cerium may be used. If obsti-
nate, the stomach should be washed out daily.
Constipation is a frequent and troublesome feature of most forms of indi-
gestion. Occasionally small doses of mercury, podophyllin, the laxative min-
eral waters, sulphur, and cascara may be employed. Glycerin suppositories
or the injection of from half a teaspoonful to a teaspoonful of glycerin is
very efficacious.
DISEASES OF THE STOMACH. 467
Many cases of chronic dyspepsia are greatly benefited by the use of mineral
waters, particularly a residence at the springs with a careful supervision of
the diet and systematic exercise.
III. DILATATION OF THE STOMACH (Gastrectasis).
Etiology. — Acute dilatation is a rare condition, described by Hilton
Fagge, characterized by sudden onset, vomiting of enormous quantities of fluid,
and symptoms of collapse. Of 102 cases collected by Lewis A. Conner 42 fol-
lowed operation with general anesthesia. The next largest group occurs in the
course of severe diseases, or during convalescence. Cases have followed in-
juries, particularly of the head and spine. In 9 cases the symptoms came
on after a single large meal; 6 cases were associated with spinal disease, in 3
while the patients were in a plaster of Paris jacket, and in a few cases it has
come on in persons in good health. There were 74 deaths. In 69 autopsies
the duodenum was found dilated in 38 cases. In a majority of cases it is due
to a constriction of the lower end of the duodenum by traction on the mesen-
teric root, which is particvilarly apt to occur when there is a long mesentery
and when the coil of small bowel is empty and falls into the true pelvis. The
diagnosis is usually easy — repeated vomiting of large quantities of bilious non-
faecal fluid, with subnormal temperature, pain, collapse symptoms, and dis-
tended abdomen are the common features. The treatment consists in repeated
emptying of the stomach with the tube; change in posture from the dorsal to
the belly position or the knee-elbow position has been followed by prompt relief.
Operation has not proved very satisfactory.
Cheonic dilatation results from : (a) Pyloric obstruction due to nar-
rowing of the orifice or of the duodenum by the cicatrization of an ulcer,
hypertrophic stenosis of the pylorus (whether cancerous or simple), congeni-
tal stricture, or occasionally by pressure from without of a tumor or of a
floating kidney. The pylorus may be tilted up by adhesion to the liver or
gall-bladder, or the stomach may be so dilated that the pylorus is dragged
down and kinked. Adhesions about the gall-bladder may extend along the
adjacent parts of the stomach and hitch up the pylorus into the hilus of the
liver, forming a very acute kink. (&) Relative or absolute insufficiency of the
muscular power of the stomach, due on the one hand to repeated overfilling of
the organ with food and drink, and on the other to atony of the coats induced
by chronic inflammation or the degeneration of impaired nutrition, the result
of constitutional affections.
The most extreme forms are met with as a sequence of the cicatricial con-
traction of an ulcer. There may be considerable stenosis without much dila-
tation, the obstruction being compensated by hypertrophy of the muscular coats.
In the second group, due to atony of the muscular coats, we must distin-
guish between instances in which the stomach is simply enlarged and those
with actual dilatation, conditions characterized by Ewald as megalogastria
and gastrectasis respectively. The size of the stomach varies greatly in differ-
ent individuals, and the maximum capacity of a normal organ Ewald places
at about 1,600 cc. Measurements above this point indicate absolute dilatation.
Atonic dilatation of the stomach may result from weakness of the coats,
due to repeated overdistention or to chronic catarrh of the mucous membrane.
468 DISEASES OF THE DIGESTIVE SYSTEM.
or to the general muscular debility which is associated with chronic wasting
disorders of all sorts. The combination of chronic gastric catarrh with over-
feeding and excessive drinking is one of the most fruitful sources of atonic
dilatation, as pointed out by Xaun}Ti. The condition is frequently seen in
diabetics, in the insane, and in beer-drinkers. In Germany this form is very
common in men employed in the breweries. Possibly muscular weakness of
the coats may result in some cases from disturbed innervation. Dilatation
of the stomach is most frequent in middle-aged or elderly persons, but the
condition is not uncommon in children, especially in association with rickets.
Symptoms. — In atonic dilatation there may be no symptoms whatever,
even with a very greatly enlarged organ; more frequently there are the asso-
ciated features of neurasthenia, enteroptosis, and nervous dyspepsia; while in
a third group there may be all the symptoms of pyloric obstruction — vomiting
of enormous quantities, etc. There is no limit to the capacity of the organ
in this condition. Gould and Pyle mention an instance in which the stomach
held 70 pints !
The features of pyloric ohstruction_, from whatever cause, are usualh' very
evident. Dyspepsia is present in nearly all cases, and there are feelings of
distress and uneasiness in the region of the stomach. The patient may com-
plain much of hunger and thirst and eat and drink freely. The most charac-
teristic symptom is the vomiting at intervals of enormous quantities of liquid
and of food, amounting sometimes to four or more litres. The material is
often of a dark-grayish color, with a characteristic sour odor due to the
organic acids present, and contains mucus and remnants of food. On stand-
ing it separates into three layers, the lowest consisting of food, the middle
of a turbid, dark-gray fluid, and the uppermost of a brownish froth. The
microscopical examination shows a large variety of bacteria, yeast fungi, and
the sarcina ventriculi. There may also be cherry stones, plum stones, and
grape seeds.
The hydrochloric acid may be absent, diminished, normal, or in excess,
depending upon the cause of the dilatation. The fermentation produces lactic,
butyric, and, possibly, acetic acid and various gases.
In consequence of the small amount of fluid which passes from the stom-
ach or is absorbed there are constipation, scanty urine, and extreme drjmess
of the skin. The general nutrition of the patient suffers greatly; there is loss
of flesh and strength, and in some cases the most extreme emaciation. The
gastric tetany will be considered in the section on that disease.
Physical Sigxs. — Inspection. — The abdomen may be large and promi-
nent, the greatest projection occurring below the navel in the standing posture.
In some instances the outline of the distended stomach can be plainly seen,
the small curvature a couple of inches below the ensiform cartilage, and the
greater curvature passing obliquely from the tip of the tenth rib on the left
side, toward the pubes, and then curving upward to the right costal margin.
Too much stress can not be laid on the importance of inspection. Yerj often
the diagnosis may be made de visu. Active peristalsis may be seen in the
dilated organ, the waves passing from left to right. Occasionally anti-peri-
stalsis may be seen. In cases of stricture, particularly of MqDertrophic stenosis,
as the peristaltic wave reaches the pylorus, the tumor-like thickening can
sometimes be distinctlv seen through the thin abdominal wall. To stimulate
DISEASES OF THE STOMACH. 469
the peristalsis the abdomen may be flipped with a wet towel. Inflation may
be practised with carbonic-acid gas, A small teaspoonful of tartaric acid
dissolved in an ounce of water is first given^ then a rather larger quantity of
bicarbonate of soda. In many cases, particularly in thin persons, the outline
of the dilated stomach stands out with great distinctness, and waves of peri-
stalsis are seen in it.
Palpation. — The peristalsis may be felt, and usually in stenosis the tumor
is evident at the pylorus. The resistance of a dilated stomach is peculiar,
and has been aptly compared to that of an air cushion. Bimanual palpation
elicits a splashing sound — dapotage — which is, of course, not distinctive, as
it can be obtained whenever there is much liquid and air in the organ. The
splashing may be very loud, and the patient may produce it himself by sud-
denly depressing the diaphragm, or it may be readily obtained by shaking
him. The gurgling of gas through the pylorus may be felt.
Percussion. — The note is tympanitic over the greater portion of a dilated
stomach; in the dependent part the note is flat. In the upright position the
percussion should be made from above downward, in the left parasternal line,
until a change in resonance is reached. The line of this should be marked,
and the patient examined in the recumbent position, when it will be found
to have altered its level. When this is on a line with the navel or below it,
dilatation of the stomach may generally be assumed to exist. The fluid may
be withdrawn from the stomach with a tube, and the dulness so made to
disappear, or it may be increased by pouring in more fluid. In cases of doubt
the organ should be artificially distended with carbonic-acid gas in the manner
described above. The most accurate method of determining the size of the
stomach is by inflation through a stomach-tube with a Davidson's syringe.
Pacanowski has shown that the greatest vertical diameter of gastric resonance
in the normal stomach varies from 10 to 14 cm, in the male and is about 10
cm. in the female.
Auscultation. — The dapotage or succussion can be obtained readily. Fre-
quently a curious sizzling sound is present, not unlike that heard when
the ear is placed over a soda-water bottle when first opened. It can be heard
naturally, and is usually evident when the artificial gas is being generated.
The heart sounds may sometimes be transmitted with great clearness and
with a metallic quality.
Mensuration may be used by passing a hard sound into the stomach until
the greater curvature is reached. Normally it rarely passes more than 60 cm.,
measured from the teeth, but in cases of dilatation it may pass as much
as 70 cm.
Diagnosis. — The diagnosis can usually be made without much difficulty.
I would like to emphasize again the great value of inspection, particularly
in combination with inflation of the stomach with carbonic-acid gas. Curious
errors, however, are on record, one of the most remarkable of which was the
confounding of dilated stomach with an ovarian cyst; even after tapping and
the removal of portions of food and fruit seeds, abdominal section was per-
formed and the dilated stomach opened. The diagnosis of ascites has been
made and the abdomen opened. The prognosis depends upon the cause; it
is good in simple atony, bad in cancerous stricture, fairly good in simple
stricture, from whatever cause.
470 DISEASES OF THE DIGESTIVE SYSTEM.
Treatment. — In the cases due to atom- careful regulation of the diet and
proper treatment of the associated catarrh will suffice to effect a cure. Strych-
nine, ergot, and iron are recommended. Washing out the stomach is of great
service, though we do not see such striking and immediate results in this
form. In cases of mechanical obstruction the stomach should be emptied and
thoroughly washed, either with warm water or with an antiseptic solution.
We accomplish in this way three important things: We remove the weight,
which helps to distend the organ; we remove the mucus and the stagnating
and fermenting material which irritates and inflames the stomach and im-
pedes digestion; and we cleanse the inner surface of the organ by the appli-
cation of water and medicinal substances. The patient can usually be taught
to wash out his own stomach, and in a case of dilatation from simple stricture
I have known the practice to be followed daily for three years with great
benefit. The rapid reduction in the size of the stomach is often remarkable,
the vomiting ceases, the food is taken readily, and in many cases the general
nutrition improves rapidly. As a rule, once a day is sufficient, and it may
be practised either the first thing in the morning or before going to bed. So
soon as the fermentative processes have been checked lukewarm water alone
should be used.
The food should be taken in small quantities at frequent intervals, and
should consist of scraped beef, Leube's beef solution, and tender meats of all
sorts. Fatty and starchy articles of diet are to be avoided. Liquids should
be taken sparingly.
Surgery should be resorted to early in cases of organic stricture ; in atonic
dilatation, after all other measures have been given a thorough trial, gastro-
enterostomy may be advised.
IV. THE PEPTIC ULCER, GASTRIC AND DUODENAL.
The round, perforating, simple or peptic ulcer is usually single, and
occurs in the stomach and in the duodenum as far as the papilla. All post-
mortem statistics show a great preponderance of the gastric ulcer, but the
enormous experience of surgeons has taught us that in more than fifty per
cent of the clinical cases the ulcer is outside the pyloric ring.
Erosions. — Small abrasions of the mucosa — 2 to 4 mm. — ^usually multiple,
are common, extending half-way or quite through the laj-er.- They are often
called hgemorrhagic erosions from their blood-stained appearance. They are
met with in the new-born, in cachectic states in children, in chronic heart and
arterial disease, in cirrhosis of the liver, etc. Of no clinical importance, as a
rule, occasionally an acute hemorrhagic erosion of quite small size opens a
large arter}^ and the patient bleeds to death. There is no difference between
this condition and the acute form of the gastric ulcer.
In many cases of chronic dyspepsia small fragments of the mucosa are
washed out by the stomach tube, and Einhorn thinks that this may be a special
form characterized by pains, dyspepsia, and weakness.
In certain acute infections with the pneumococcus (Dieulafoy) and septic
organisms there may be hsemorrhagic erosions, which occasionally prove fatal
by hsematemesis.
And, lastly, it is probable that the post-operative hsematemesis, slight or
DISEASES OF THE STOMACH. 471
grave, may be due to these erosions. The French have described them as if
peculiar to operations for appendicitis (vomito-negro appendiculaire) , but
we have had many cases after all sorts of abdominal operations. It is prob-
able that the slight gastric haemorrhages which occur in connection with the
throbbing aorta in neurotic women are due to these erosions.
Etiology of Peptic Ulcer. — Incidence. — It is more common in Great Brit-
ain and on the Continent than in America. There were 2.3 per cent in Edin-
burgh (Bramwell), 0.74 per cent in London (Fenwick), 1.33 per cent in
Berlin, and 0.57 per cent among 161,589 medical admissions in America
(Campbell Howard). It is more common in the northeastern section of the
United States — :1.74 per cent, Massachusetts General Hospital (Greenough
and Joslin), 0.18 per cent in fifteen years at the Johns Hopkins Hospital in
all services among a total admission of 44,378 (Campbell Howard). Among
10,841 post mortems in the United States and Canada there were only 144
cases of ulcer — 1.33 per cent, against 5 per cent on the Continent and 4.3
per cent in London.
8ex. — Of 1,699 cases collected from hospital statistics by W. H. Welch
and examined post mortem, 40 per cent were in males and 60 per cent were
in females. In 83 cases (J. H. H.) there were 48 males and 38 females — in
striking contrast to the Massachusetts General Hospital figures, 5 females to
1 male. Eecent surgical statistics show a preponderance of males.
• Age. — In females the largest number of cases occurred between fifteen and
twenty-five; in males between forty and fifty, in our series. It may occur in
old people. E. G. Cutler has studied a series of 39 cases in children. In 6
the symptoms came on immediately after birth. There were 8 cases under
seven years of age, and 9 between eight and thirteen.
Heredity appears to play a part in some cases (Dreschfeld).
Occupation. — It was impossible in our series to say that occupation had
any influence. Among women, chlorotic, dyspeptic servant girls seem very
prone. Shoemakers are thought to be specially liable. It appears relatively
more common in the hospital classes.
Trauma. — Ulcers have been known to follow a blow in the region of the
stomach. There was a history of injury in 7 cases in our series.
Associated Diseases. — Anaemia and chlorosis predispose strongly to gastric
ulcer, particularly in women and in association with menstrual disorders. A
very considerable number of all cases of gastric ulcer occur in chlorotic girls.
It has been found also in connection with disease of the heart, arterio-sclerosis,
and disease of the liver. The tuberculous and syphilitic ulcers of the stomach
have already been considered.
Burns. — The duodenal ulcer may follow large superficial burns. Perry
and Shaw found it in five of one hundred and forty-nine autopsies in cases of
burns of the skin.
Morbid Anatomy and Pathology. — Ninety per cent of gastric ulcers are to
be found at the pyloric end; nearly all duodenal ulcers are in the first or
ascending portion, and more than one-half extend up to or within three-
fourths of an inch of the pylorus, while twenty per cent involve the margin
of the pyloric ring (Mayo). It may not be easy on the operating table to
distinguish between an ulcer of the duodenum and that of the stomach, but
Mayo says that the position of the pyloric vein gives the exact location. Mul-
472 DISEASES OF THE DIGESTIVE SYSTEM.
tiple ulcers ma}" occur, 8.2 per cent in Mayo's series. From 5 to 3-1 liave
been found. In the stomach post-mortem statistics (Welch) give in 793
cases, 288 on the lesser curvature, 235 on the posterior -wall, 69 on the ante-
rior wall, 95 at the pylorus, 50 at the cardia, 29 at the fundus, and 27 on
the greater curvature.
The acute ulcer is usually small, punched out, the edges clean-cut, the floor
smooth, and the peritoneal surface not thickened. The chronic ulcer is of
larger size, the margins are no longer sharp, the edges are indurated, and the
border is sinuous. It may reach an enormous size, as in the one reported by
Peabody, which measured 19 by 10 cm. and -involved all of the lesser curva-
ture and spread over a large part of the anterior and posterior walls. The
sides are often terraced. The floor is formed either by the submucosa, by the
muscular layers, or, not infrequently, by the neighboring organs, to which the
stomach has become attached. In the healing of the ulcer, if the mucosa is
alone involved, the granulation tissue grows from the edges and the floor and
the newly formed tissue gradually contracts and unites the margins, leaving
a smooth scar. In larger ulcers which have become deep and involved the
muscular coat, the cicatricial contraction may cause serious changes, the most
important of which is narrowing of the pyloric orifice and consequent dila-
tation of the stomach. In the case of a girdle ulcer, hour-glass contraction
of the stomach may be produced. Large ulcers persist for years without any
attempt at healing.
Among the more serious changes which may proceed in an ulcer are the
following :
Pekfoeatiox. — This occurred in 28.1 per cent of 1,871 cases collected by
Musser. In some series (Mayo's) duodenal perforation is the more common.
Of 272 cases of duodenal ulcer in Mayo's series (to June 1, 1908), perforation
was found sixty-six times, 16 acute, 13 subacute with abscess, and 37 chronic
and protected. Perforation of the anterior wall of the stomach usually excites
an acute peritonitis. On the posterior wall the ulcer penetrates directly into the
lesser peritoneal cavity, in which case it may produce an air-containing abscess
with the s}Tnptoms of the condition known as subphrenic pyopneumothorax.
In rare instances adhesions and a gastrocutaneous fistula form, usually in the
umbilical region. Fistulous communication with the colon may also occur,
or a gastroduodenal fistula. The pericardium may be perforated, and even
the left ventricle. Perforation into the pleura may also occur. It is to be
noted that general emphysema of the subcutaneous tissues occasionally follows
perforation of a gastric ulcer.
Erosiox of Blood-vessels. — In both forms of ulcer haemorrhage occurs, in
8.1 per cent of Musser's series of 1,871 cases. In Mojuihan's 11-i cases of
duodenal ulcer, hsemorrhage occurred in 41. It is more common in the chronic
form. Ulcers on the posterior wall may erode the splenic artery, but perhaps
more frequently the bleeding proceeds from the artery of the lesser curvature.
In the case of duodenal ulcer the pancreaticoduodenal artery may be eroded or
(as in one of my cases) fatal hemorrhage may result from the opening of the
hepatic artery, or more rarely the portal vein. Interesting changes occur in the
vessels. Embolism of the artery supph'ing the ulcerated region has been met
with in several cases; in others diffuse endarteritis. Small aneurisms have
been found in the floor of the ulcers by Douglas Powell, Welch, and others.
DISEASES OF THE STOMACH. 473
A rare event is emphysema of the siib-pcritoneal tissue, which may be very
extensive and even pass on to the posterior mediastinum. Jurgensen ascribes
it to entrance of air into the veins, but Welch thinks it represents an invasion
with the gas bacillus.
CiCATEizATiON. — Superficial ulcers often heal without leaving any serious
damage. Stenosis of the pyloric orifice not infrequently follows the healing
of an ulcer in its neighborhood. In other instances the large annular ulcer
may cause in its cicatrization an hour-glass contraction of the stomach. The
adhesion of the ulcer to neighboring parts may subsequently be the cause
of much pain. The parts of the mucosa in the neighborhood of the ulcer
frequently show signs of chronic gastritis.
Perigastric Adhesions. — The condition is common, as high as 5 per
cent of post-mortem records. It follows ulcer, lesions of the gall-bladder,
pancreatic disease, syphilitic disease of the liver, and chronic tuberculosis.
In some instances the lesions are quite extensive, and the condition has been
called plastic perigastritis. It may be associated, too, with hypertrophic thick-
ening of the coats of the stomach and with chronic plastic peritonitis. In
some instances the pylorus may be narrowed as a result of the adhesions, or
a sort of hour-glass stomach may be produced, or the motility of the organ
is interfered with. Mayo Eobson in 1893 called attention to this condition.
As Hale White has pointed out, pain is the most constant feature in this con-
dition, and it may simulate that of gastric ulcer or of hyperacidity, and may
be present constantly or at intervals. It is much influenced by posture and
usually relieved by pressure. Local tenderness is present in a majority of
instances. The cases are chronic, the general health is but slightly interfered
with, and there are not, as a rule, signs of gastric dilatation. A definite tumor
may be present about the region of the pylorus. E. P. Paton has collected
42 cases on which operation has been performed, apparently in a majority of
the cases with benefit.
Mode of Origin. — The mode of origin is unknown. The anatomical basis
is an interference with the blood supply in a limited area of the mucosa, at-
tributed to embolism, thrombosis, or spasm of the vessels. As the arteries of
the stomach are not end vessels, simple obstruction can not account for it.
Trophic influences, bacterial necrosis of the mucosa, spasm of the muscular
coat in limited areas, etc., are among the hypotheses which have been ad-
vanced. The erosion is effected by the gastric juice, and the healing is prob-
ably retarded by its high grade of acidity.
The duodenal ulcer has an identical origin. A few cases of acute ulcer
have a curious relation with superficial burns. Bardeen's researches upon
the necroses in the viscera following extensive burns throw an important light
upon these cases, showing especially how the gastro-intestinal mucous mem-
brane is implicated in the toxic effects.
The jejunal peptic ulcer, of which more than 30 cases have been recorded,
is a very serious sequel of gastro-enterostomy.
Symptoms. — The condition may be latent and only met with accidentally,
post mortem. The first symptoms may be those of perforation. In other
cases again, for months and years, the patient has had dyspepsia, and the
ulcer may not have been suspected until the occurrence of a sudden haemor-
rhage.
32
474 DISEASES OF THE DIGESTIVE SYSTEM.
Dyspepsia may be slight and trifling or of a most aggravated character.
In a considerable proportion of all cases nausea and vomiting occur, the
latter not for two or more hours after eating. The vomitus usually contains
a large amount of hydrochloric acid.
HEMORRHAGE is present in at least one-third of all cases. It may be
latent (occult). A patient may feel faint and turn pale and sweat; the next
day the stools may be tarry from the blood that has passed into the small
bowel. These concealed hsemorrhages are more often small, and the blood
is not readily seen in the vomitus or stools. Weber's test may be tried; the
fluid to be examined is mixed with 2 or 3 cc. of glacial acetic acid, and then
shaken with sulphuric ether. If blood be present the ethereal extract has a
Tokay wine-like color. Meat should not be eaten for a few days before the test
is made. These small, latent haemorrhages may cause a slowly progressive
anaemia. More commonly the bleeding is profuse, and the blood may be in
such quantities and brought up so quickly that it is fluid, bright red in color,
and quite unaltered. When it remains for some time in the stomach and is
mixed with food it may be greatly changed, but the vomiting of a large quan-
tity of unaltered blood is very characteristic of ulcer. As a rule, there are
only one or two attacks; in our series 7 cases had one haemorrhage, 7 two, 11
three, 1 four, and 15 many (Howard). Profuse bleedings may occur at inter-
vals for many years. Death may follow directly. From 16 to 18 per cent of
the fatal cases are due to it (S. and W, Fenwick).
The immediate effect of the haemorrhage is a severe ansemia, from which
it may take months to rally; slight fever is common. Eare and untoward
effects are convulsions, sometimes only the usual convulsions of extreme cere-
bral anaemia from which recovery takes place, or they may precede a hemi-
plegia, due probably to thrombosis.
Amaurosis may follow the haemorrhage, and unfortunately may be perma-
nent, and is due to degeneration of the retinal ganglion cells, or to a throm-
bosis of the cerebral arteries or veins.
Pain is perhaps the most constant and distinctive feature of ulcer. It
varies greatly in character; it may be only a gnawing or burning sensation,
which is particularly felt when the stomach is empty, and is relieved by taking
food, but the more characteristic form comes on in paroxysms of the most
intense gastralgia, in which the pain is not only felt in the epigastrium, but
radiates to the back and to the sides. In many cases the two points of epi-
gastric pain and dorsal pain, about the level of the tenth dorsal vertebra, are
very well marked. These attacks are most frequently induced by taking food,
and they may recur at a variable period after eating, sometimes within fifteen
or twenty minutes, at others as late as two or three hours. It is usually stated
that when the ulcer is near the cardia the pain is apt to set in earlier, but
there is no certainty on this point. In some cases it comes on in the early
morning hours. The attacks may occur at intervals with great intensity for
weeks or months at a time, so that the patient constantly requires morphia,
then again they may disappear entirely for a prolonged period. In the attack
the patient is usually bent forward, and finds relief from pressure over the
epigastric region; one patient during the attack would lean over the back of
a chair; another would lie flat on the floor, with a hard pillow under the
abdomen. Pressure is, as a rule, grateful. It has been thought that the
DISEASES OF THE STOMACH. 475
posture assumed during the attack would indicate the site of the ulcer, but
this is very doubtful.
Tenderness on pressure is a common symptom in ulcer, and patients
wear the waist-band very low. Pressure should be made with great care, as
rupture of an ulcer is said to have been induced by careless manipulation.
In old ulcers with thickened bases an indurated mass can usually be felt
in the neighborhood of the pylorus.
Of general symptoms, loss of weight results from the prolonged dyspepsia,
but it rarely, except in association with cicatricial stenosis of the pylorus,
reaches the high grade met with in cancer. The ancemia may be extreme, and
in one case of duodenal ulcer, which I examined, the blood-count was as low
as 700,000 per c. mm. Of 44 cases in my wards in which blood-counts were
made, the lowest was 1,902,000 per c. mm. There are instances, such as the
one reported by Pepper and Griffith, in which the extreme anaemia can not
be explained by the occurrence of hgemorrhage. In a few instances polycythse-
mia is present, even after a hgemorrhage, due to concentration of the blood
and possibly associated dilatation of the stomach. In a few cases parotitis
occurs, with the perforation sometimes, or after a haemorrhage. In one of
my cases there was a remarkable pigmentation of the face and of the axillary
folds.
Perforation. — This occurred in 28.1 per cent of Musser's series. The
acute, perforating form is much more common in women than in men. The
symptoms are those of perforative peritonitis. Particular attention must be
given to this accident since it has come so successfully within the sphere of the
surgeon. As already mentioned, perforation may take place either into the
lesser peritoneum or into the general peritoneal cavity, in both of which cases
operation is indicated; in rare instances the ulcer may perforate the peri-
cardium. This was the case in 10 of 28 cases in which the diaphragm was
perforated (Pick).
Localized, more frequently subphrenic, abscess may follow perforation.
Urine. — Albumin is occasionally present; in 14 of our series with dilata-
tion of the stomach. Indican may be present. Acetone and diacetic acid
(with syncopal attacks) have been described by Dreschfeld.
Hour-glass stomach most frequently results from the cicatrization of
an ulcer. In a few cases it is congenital. The symptoms, fairly character-
istic, are thus given by Moynihan:
(1) In washing out the stomach part of the fluid is lost. (2) If the stom-
ach is washed clean, a sudden reappearance of stomach contents may take
place. (3) "Paradoxical dilatation" when the stomach has apparently been
emptied, a splashing sound may be elicited by palpation of the pyloric seg-
ment. (4) After distending the stomach, a change in the position of the
distention tumor may be seen in some cases. (5) Gushing, bubbling, or
sizzling sounds are heard on dilatation with carbon dioxide at a point distinct
from the pylorus. ( 6 ) In some cases, when both parts are dilated, two tumors
with a notch or sulcus between are apparent to sight or touch.
Prognosis. — In all statistics the acute and chronic ulcer have been consid-
ered together. The former is more amenable to medical treatment, but grave
complications may occur even before the digestive symptoms have been very
pronounced. The chronic ulcer may last for years — twelve, eighteen, or even
476 DISEASES OF THE DIGESTIVE SYSTEM.
t-sveiity — with intervals of good health. The all-important point in the prog-
nosis relates to the question of medical or surgical treatment — which gives the
best results ? So far as figures count, the exhaustive study of Musser favors the
former, 12.4 per cent mortality against 20 per cent for the latter. This for
simple cases including complications. In private practice many series of cases
have not a mortality above 6 per cent. The mortality of the chronic peptic
ulcer in the hands of such experts as the Mayos and Moynihan is very low.
In 311 gastrojejunostomies for ulcer of the stomach and duodenum the mor-
tality was less than 1 per cent, and only three patients required a secondary
operation (Mayo's). Of Mo}Tiihan's cases of duodenal ulcer, ll-l in number
(exclusive of perforation), there were only two deaths. The end results of
gastro-enterostomy for the chronic ulcer appear to be excellent.
Diagnosis. — The acute non-indurated ulcer may cause very few symptoms
— nothing beyond ordinar}"- dyspepsia with pain. Examination of the stomach
contents shows an increase in the free HCl. Hsematemesis may be the first
s}-mptom of moment. This group of cases is seen chiefly in young girls, and
appears to be much more common in England than in the United States. A
condition which may be confounded with it is gasirorrli exis, described hj Hale
White. The stomach s}Tnptoms are marked, the bleeding may be profuse, but
post mortem or at operation no ulcer is found. Of course very careful inspec-
tion must be made, as fatal bleeding may come from a very small erosion.
The symptoms of non-indurated mucous ulcer yield to a few months' medical
treatment.
From gastralgia, dyspepsia, and hyperchlorhydria the diagnosis of the
chronic, indurated peptic ulcer is very difficult; in many of those conditions,
indeed, surgeons have shown clearly that the symptoms are due to an ulcer.
That the brothers Mayo should have operated (to June 1, 1908) on 272 cases of
duodenal ulcer (as many almost as have been reported in the whole literature)
and that Mo}-nihan should have had to June, 1908, 174 cases, indicates that we
physicians have been napping, and that what the modern " gastro-enterolo-
gist " needs is a prolonged course of study at such surgical clinics as Eochester
(Minnesota) or Leeds. It is not as if there were any possibility of mistake, as
these are men whose ways and work are known to all. More particularly is
the diagnosis of duodenal ulcer important since its relative frequency has been
demonstrated. The following account condensed from Moynihan is a picture of
hyperchlorhydria plus in the severe cases the hsematemesis or melaena. After,
food the patient is free from pain and the hour or two following a meal is the
best time in the day. Varying from one and a half to four hours after the
meal, a sense of uneasiness is noticed in the upper part of the abdomen. A
burning, gnawing sensation develops with a bitter taste in the mouth and eruc-
tations of food or gas. The pain, which gradually increases, may be relieved
by belching, or by pressure. As it increases in severity, it strikes through to
the back, to the right of the middle line, and it may radiate round the right
side of the chest. Patients discover for themselves that food relieves the pain,
and many carry a biscuit in their pockets, or take milk, a dose of an alkaline
medicine, or some form of food as soon as the uneasiness develops. It will
often be found that a patient names certain hours as those at which the pain
is noticed, 11 a.m., 4 p.m., or 2 a.m. These are all a few hours after food.
Many patients wake up, after a short sleep, with an intense gnawing pain in
DISEASES OF THE STOMACH. 477
the pit of the stomach; and they may keep a few biscuits, or some bread and
butter, or a glass of milk at the bedside, so that, on waking, the food is taken to
relieve the pain. The pain may be more severe, in fact, indistinguishable from
a mild form of hepatic colic, coming on two or three hours after food, as a
" colic " or a " spasm." As the pain comes on at a time when the patient begins
to feel hungry for his next meal, the term " hunger-pain " seems appropriate.
A feeling of flatulent distention in the epigastrium is often very distressing;
some patients describe it as the most intolerable of all their symptoms. The
appetite is generally good, if stenosis has not developed. It is not unusual for
a patient to say : " I've a good appetite, I can take anything, and I never
vomit." After a time, a few weeks, a month or two, the symptoms may gradu-
ally improve, and even disappear, to reassert themselves after a longer or
shorter interval. In the intervals of these attacks, he may be perfectly well,
enjoy food, and gain weight. Vomiting is an infrequent symptom of duodenal
ulceration, it comes as a constant symptom only when stenosis is present. Ex-
amination of the surface of the abdomen will generally reveal a tender area
a little above and slightly to the right of the umbilicus. The most serious of
the symptoms, which result from duodenal ulceration, is haemorrhage, which
may be manifest as hsematemesis or melsena alone. In nearly 40 per cent of
the cases ulcer of the stomach also is present, and in such the pain comes
earlier after food and the tenderness on pressure is higher and to the left.
The experience of surgeons has taught us that a number of cases in which
the pains were regarded as gastralgia have in reality been due to gall-stones,
with which, as is now well known, jaundice is not necessarily connected.
Treatment. — Post-mortem observations show that a very large number of
ulcers heal completely, but the process is slow and tedious, often requiring
months, or, in severe cases, years. The following are the important points
in treatment:
(a) Absolute rest in bed.
(&) A carefully and systematically regulated diet. While theoretically
it is better to give the stomach complete rest by rectal feeding, yet in prac-
tice this strict limitation is not found satisfactory. The food should be
bland, easily digested, and given at stated intervals. The following dietary
will be found useful : At 8 a. m. give 200 cc. of Leube's beef solution ; at
12 M., 300 cc. of milk gruel or peptonized milk. The gruel should be made
with ordinary flour or arrowroot, and is mixed with an equal quantity of
milk. If necessary it may be peptonized. Buttermilk is very well borne
by these patients. At 4 p. m. the beef solution again, and at 8 p. m. the milk
gruel or the buttermilk.
The stomach in some cases is so irritable that the smallest amount of
food is not well borne. In such cases lavage may be practised, if necessary,
every morning, with mildly alkaline water, after which the beef solution is
given and the feeding supplemented by the rectal injections. Ill effects rarely
follow the careful use of the stomach tube in gastric ulcer. There are some
cases which do well from the outset on a milk diet, given at regular intervals,
3 or 4 ounces every two hours. When milk is not well borne egg albumen
may be substituted, or the whites of eight eggs may be alternated with Leube's
beef solution. At the end of a month, if the condition has improved, the
patient may be allowed scraped beef or young chicken, perfectly fresh sweet-
478 DISEASES OF THE DIGESTIVE SYSTEM.
bread, and farinaceous puddings made with milk and eggs. Local applica-
tions, such as warm fomentations, over the abdomen are very useful. The
patient should be told that the treatment will take at least three months, and
for the greater portion of the time he should be in bed.
(c) Medicinal measures are of very little value in gastric ulcer, and the
remedies employed probably do not benefit the ulcer, but the gastric catarrh.
The Carlsbad salts are warmly recommended by von Ziemssen. The artificial
preparation (sulphate of sodium, 50 parts; bicarbonate of sodium, 6; chloride
of sodium, 3) may be substituted, of which a teaspoonful is taken every morn-
ing. Bismuth, in doses of 30 to 60 grains three times a day, and nitrate of
silver may be given, but they influence the associated conditions rather than
the ulcer.
The pain, if severe, requires opium. Unless the gastralgia is intense mor-
phia should not be given hypodermically, as there is a very serious danger
in these cases of establishing the morphia habit. Doses of an eighth of a
grain, with the bicarbonate of soda and bismuth, will allay the mild attacks,
but the very severe ones require the hypodermic injection of a quarter or often
half a grain. Antipyrin and antifebrin may be tried, but, as a rule, are quite
ineffectual. In the milder attacks Hoffman's anodyne, or 20 or 30 drops of
spirits of chloroform, or the spirits of camphor will give relief. Counter-
irritation over the stomach with mustard or cantharides is often useful.
When the stomach is irritable, the patient should be fed per rectum.
He will sometimes retain food which is passed into the stomach through the
tube, and Leube's beef solution or milk may be given in this way. Cracked
ice, chloroform, oxalate of cerium, bismuth, hydrocyanic acid, and ingluvin
may be tried. When hsemorrhage occurs the patient should be put under
the influence of opium as rapidly as possible. No attempt should be made
to check the haemorrhage by administering medicines by the mouth; as the
profuse bleeding is always from an eroded artery, frequently from one of
considerable size, it is doubtful if acetate of lead, tannic and gallic acids, and
the usual remedies have the slightest influence. The essential point is to
give rest, which is best obtained by opium. Ergotin may be administered
hypodermically in two-grain doses. Nothing should be given by the mouth
except small quantities of ice. In profuse bleeding a ligature may be applied
around a leg, or a leg and arm. Not infrequently the loss of blood is so great
that the patient faints. A fatal result is not, however, very common from
haemorrhage. Transfusion, direct from artery to vein by Crile's method, may
be necessary, or the subcutaneous infusion of saline solution.
The patients usually recover rapidly from the haemorrhage and require
iron in full doses, which may, if necessary, be given hypodermically.
Surgical interference is indicated : ( 1 ) In the chronic indurated ulcer.
Experience has shown that after gastro-enterostomy the ulcer heals rapidly,
and in some cases the ulcer itself may be located; (3) in all cases when the
ulcer has caused mechanical interferences with 'the passage of the gastric con-
tents; (3) in all cases associated with recurring haemorrhages. In young girls
the single severe attack of haematemesis may be a simple gastrorrhexis, or from
a simple ulcer that heals readily, but in men severe haematemesis is almost
always from the chronic ulcer. (4) In the perigastric adhesions after chronic
ulcer operation is sometimes helpful.
DISEASES OF THE STOMACH. 479
In the present state of our knowledge it is not easy to determine the limits
of medical and surgical practice in the treatment of peptic ulcer. The old
statistics are not of much avail, since it is quite clear that scores of cases have
been masquerading under the names of hyperchlorhydria, acid dyspepsia, and
so forth. The simple non-indurated ulcer is, in the majority of cases, a medi-
cal disease. A chronic indurated form is best treated surgically. It is not
always easy to say when a given case ceases to be medical. Much will depend
on the technical skill available. Gastro-enterostomy is not in all hands a sim-
ple affair, and while the chronic ulcer is slow and hard to heal, and has many
possibilities for evil, it is not a killing disease.
V. CANCER OF THE STOMACH.
Etiology. — Incidence. — In an analysis of 30,000 cases of cancer, W. H..
Welch found the stomach involved in 21.4 per cent, this organ thus standing
next to the uterus in order of frequency. Among 8,464 cases admitted to my
wards, there were 150 cases of cancer of the stomach. There were 39 cases
among the first 1,000 autopsies in the post-mortem room of the Johns Hopkins
Hospital. The disease is more common in some countries. Figures indicate
that cancer of the stomach, as of other organs, is increasing in frequency.
Sex. — T. McCrae has analyzed 150 cases from my wards and found that
there were 126 males and 24 females. Welch gives the ratio as 5 to 4.
Age. — Of our 150 cases the ages were as follows : Between twenty and
thirty, 6; from thirty to forty, 17; forty to fifty, 38; fifty to sixty, 49; sixty
to seventy, 36; seventy to eighty, 4. Fifty-eight per cent occurred between
the ages of forty and sixty. Of the 6 cases occurring under the thirtieth
year, the youngest was twenty-two. Of the large number of cases analyzed
by Welch, three-fourths occurred between the fortieth and seventieth years.
Congenital cancer of the stomach has been described, and cases have been met
witli in children.
Race. — Among our 150 cases, 131 were white; 19 were negroes.
Heredity. — Of the 150 cases in only 11 was there a positive history of
cancer in the family. In some families, as the Bonapartes, the disease seems
to prevail. In our series a very much larger number — 38 — ^had a family
history of tuberculosis.
Previous Diseases, Habits, etc. — A history of dyspepsia was present in
only 33 cases; of these, 17 had had attacks at intervals, 11 had had chronic
stomach trouble, and 5 had had dyspepsia for one or two years before the
symptoms of cancer developed. Napoleon, discussing this interesting point
with his physician Autommarchi, said that he had always had a stomach of
iron and felt no inconvenience until the onset of what proved to be his
fatal illness.
Alcohol. — Seventy-seven of our patients had used it regularly, 65 of these
moderately (?), 8 excessively. Trauma. — Only one case gave a positive his-
tory. In one case the cancer followed rapidly upon a blow on the stomach,
and the patient lost sixty pounds in weight in three months. Gastric Ulcer.
— Four cases gave a history pointing to ulcer, but there was no instance of
ulcus carcinomatosum among the autopsies.
Mental worry and strain were given occasionally as causes of the illness.
480 DISEASES OF THE DIGESTIVE SYSTEM.
Morbid Anatomy. — The most common varieties of gastric cancer are the
cylindrical-celled adeno-carcinoma and the encephaloid or medullary car-
cinoma; next in frequency is scirrhous, and then colloid cancer. With
reference to the situation of the tumor, Welch analyzed 1,300 cases, in
which the distribution was as follows: Pyloric region, 791; lesser curvature^
148; cardia, 104; posterior wall, 68; the whole or greater part of the
stomach, 61; multiple tumors, 45; greater curvature, 34; anterior wall, 30;
fundus, 19.
The medullary cancer occurs in soft masses, which involve all the coats
of the stomach and usually ulcerate early. The tumor may form villous
projections or cauliflower-like outgroT\i:hs. It is soft, grajdsh white in color,
and contains much blood. Microscopically it shows a scanty stroma, enclosing
alveoli which contain irregular polyhedral and cylindrical cells. The cylin-
drical-celled epithelioma may also form large irregular masses, but the con-
sistence is usually firmer, particularly at the edges of the cancerous ulcers.
Microscopically the section shows elongated tubular spaces filled with col-
umnar epithelium, and the intervening stroma is abundant. Cysts are not
uncommon in this form. The scirrhous variety is characterized by great hard-
ness, due to the abundance of the stroma and the limited amount of alveolar
structures. It is seen most frequently at the pylorus, where it is a common
cause of stenosis. It may be combined with the medullary form. It may
be diffuse, involving all parts of the organ, and leading to a condition which
can not be recognized macroscopically from cirrhosis. This form has also
been seen in the stomach secondary to cancer of the ovaries. In connection
with the diffuse carcinomatosis there may be simultaneous involvement of the
small and large intestines, as in the three remarkable cases reported by Kut-
tall and Emanuel. The colloid cancer is peculiar in its wide-spread invasion
of all the coats. It also spreads with greater frequency to the neighboring
parts, and it occasionally causes extensive secondary growths of the same
nature in other organs. The appearance on section is very distinctive, and
even with the naked eye large alveoli can be seen filled with the translucent
colloid material. The term alveolar cancer is often applied to this form.
Ulceration is not constantly present, and there are instances in which, with
most extensive disease, digestion has been but slightly disturbed. There is a
specimen in the Warren Museum, at the Harvard Medical School, of the most
wide-spread colloid cancer, in which the stomach contained after death large
pieces of undigested beef-steak.
Secoxdary Caxcer of the Stomach, — Of 37 cases collected by Welch,
17 were secondary to cancer of the breast. Among the first 1,000 autopsies at
the Johns Hopkins Hospital there were 3 cases of secondary cancer.
Changes in the Stomach. — Cancer at the cardia is usually associated
with wasting of the organ and reduction in its size. The oesophagus above the
obstruction may be greatly dilated. On the other hand, annular cancer at
the pylorus causes stenosis with great dilatation of the organ. In a few rare
instances the pylorus has been extremely narrowed without any increase in
the size of the stomach. In diffuse scirrhous cancer the stomach may be very
greatly thickened and contracted. It may be displaced or altered in shape
by the weight of the tumor, particularly in cancer of the pylorus; in such
cases it has been found in every region of the abdomen, and even in the true
DISEASES OF THE STOMACH. 481
pelvis. The mobility of the tumors is at times extraordinary and very de-
ceptive, and they may be pushed into the right hypochondrium or into the
splenic region, entirely beneath the ribs. Adhesions very frequently occur,
particularly to the colon, the liver, and the anterior abdominal wall.
Secondary cancerous growths in other organs are very frequent, as shown '
by the following analysis by Welch of 1,574 cases: Metastasis occurred in the
lymphatic glands in 551 ; in the liver in 475 ; in the peritonaeum, omentum,
and intestine in 357; in the pancreas in 123; in the pleura and lung in 98;
in the spleen in 26 ; in the brain and meninges in 9 ; in other parts in 92.
The lymph-glands affected are usually those of the abdomen, but the cervical
and inguinal glands are not infrequently attacked, and give an important clue
in diagnosis. Secondary metastatic growths occur subcutaneously, either at
the navel or beneath the skin in the vicinity, and are of great value in diagnosis.
In one instance a patient with jaundice, which had developed somewhat sud-
denly and was believed to be catarrhal, presented no signs of enlargement of
the liver or tumor of the stomach, but a nodular body appeared at the navel,
which on removal proved to be typical scirrhus. A second case in the ward
at the same time, with, an obscure doubtful tumor in the left hypochondrium,
developed a painful nodular subcutaneous growth midway between the navel
and the left margin of the ribs,
Perfokation. — In the extensive ulceration which occurs perforation of the
stomach is not uncommon. It occurred into the peritongeum in 17 of the 507
cases of cancer of the stomach collected by Brinton. In our series perforation
is recorded in 4 cases. When adhesions form, the most extensive destruction
of the walls may take place without perforation into the peritoneal cavity.
In one instance which came under my observation a large portion of the left
lobe of the liver lay within the stomach. Occasionally a gastro-cutaneous
fistula is established. Perforation may occur into the colon, the small bowel,
the pleura, the lung, or into the pericardium.
Symptoms. — Latent Carcinoma. — The cases are not very infrequent. There
may be no symptoms pointing to the stomach, and the tumor may be discov-
ered accidentally after death. In a second group the symptoms of carcinoma
are present, not of the stomach, but of the liver or some other organ, or there
are subcutaneous nodules, or, as in one of our cases, secondary masses on the
ribs and vertebrae. In a third group, seen particularly in elderly persons in
institutions, there is gradual asthenia, without nausea, vomiting, or other
local symptoms.
Features of Onset. — Of the 150 cases in our series, 48 complained of pain,
44 of dyspepsia, 21 of vomiting, 13 of loss in weight, 3 of difficulty in swallow-
ing, 1 of tumor. In 7 the features of onset suggested pernicious anaemia.
In 37 cases there was a history of sudden onset.
General Symptoms. — Loss of Weight. — Progressive emaciation is one of
the most constant features of the disease. In 79 of our cases in which exact
figures were taken: To 30 pounds, 32 cases; 30 to 50 pounds, 36 cases; 50 to
60 pounds, 5 cases; 60 to 70 pounds, 4; over 70 pounds, 1 ; 100 pounds, a case
of cancer at the cardiac end with obstruction to swallowing. The loss in
weight is not always progressive. We see increase in weight under three con-
ditions: (a) Proper dieting, with treatment of the associated catarrh of the
stomach; (&) in cases of cancer of the pylorus after relief of the dilatation
482 DISEASES OF THE DIGESTIVE SYSTEM.
of the organ by lavage, etc.; (c) after a profound mental impression. I have
known a gain of ten pounds to follow the visit of an optimistic consultant.
In Keen and D. D, Stewart's case there was a gain of seventy pounds after
an exploratory operation !
Loss in strength is usually proportionate to the loss in weight. One sees
sometimes remarkable vigor almost to the close, but this is exceptional.
Ancemia is present in a large proportion of all cases, and with the emacia-
tion gives the picture of cachexia. There is often a yellow or lemon tint of
the skin. In 59 cases careful blood-counts were made, in 3 the red corpuscles
were above 6,000,000 per cubic millimetre. This occurs in the concentrated
condition of the blood in certain cases of cancer of the pylorus with dilatation
of the stomach. The average count in the 59 cases was 3,712,186 per cubic
millimetre. In only 8 cases was the count below 2,000,000, and in none below
1,000,000. The average of the hsemoglobin was 44.9 per cent. In only 9 was
it below 30 per cent. In 62 cases in which the leucocytes were counted there
were only 18 cases in which they were above 12,000 per cubic millimetre; in
only 3 cases were they above 20,000. As mentioned, there were 7 cases in
which the features of onset suggested a primary anaemia. To this question
we shall return under diagnosis.
Among other general symptoms may be mentioned fever^ which was present
at some time in 74 of our 150 cases. In only 13 of these did the temperature
rise above 101°. In 2 it was above 103°. Fifteen presented fairly constant
elevation of temperature. Eight presented sudden rises. Two cases had
chill, with elevation to 103° and 104°. Chills may be associated with sup-
puration at the base of the cancer.
Urine. — There may be no changes throughout; in 65 of our cases there
were no alterations, in 36 albumin was found, and in 34 albumin with tube-
casts. Glycosuria, peptonuria, and acetonuria have been described. Indican
is common.
(Edema. — Swelling of the ankles is of frequent occurrence toward the
close. In some cases there is even early a general anasarca, usually in com-
bination with extreme anaemia. The cancer is usually overlooked.
The howels are often constipated. In only 12 cases in our series was
diarrhoea present. In 2 cases blood was passed per rectum. There are no
special cardiac symptoms; the pulse becomes progressively weaker. ' Throm-
bosis of one femoral vein may occur or, as in one of our cases, wide-spread
thrombosis in the superficial veins of the body.
Symptoms on the part of the nervous system are rare; consciousness is
often retained to the end. Coma may occur similar to that seen in diabetes,
and is believed to be due to an acid intoxication.
FuNCTioxAL Disturbances, — Anorexia, loss of desire for food, is a fre-
quent and valuable symptom, more constant perhaps than any other. Nausea
is a striking feature in many cases; there is often a sudden repulsion at the
sight of food. In exceptional cases the appetite is retained throughout.
Vomiting may come on early, or only after the dyspepsia has persisted
for some time. It occurred in 128 cases in our series. At first it is at long
intervals, but subsequently it is more frequent, and may recur several times
in the day. There are cases in which it comes on in paroxysms and then
subsides; in other cases, it sets in early, persists with great violence, and
DISEASES OF THE STOMACH. 483
may cause a fatal termination within a few weeks. Vomiting is more fre-
quent when the cancer involves the orifices, particularly the pylorus, in
which case it is usually delayed for an hour or more after taking the food.
When the cardiac orifice is involved it may follow at a shorter interval.
Extensive disease of the fundus or of the anterior or posterior wall may
be present without the occurrence of vomiting. The food is sometimes very
little changed, even after it has remained in the stomach for twenty-four
hours.
Hcemorrliage occurred in 36 of our 150 cases; in 33 the blood was dark
and altered, in 3 it was bright red. In 2 cases vomiting of blood was the
first symptom. The bleeding is rarely profuse; more commonly there is
slight oozing, and the blood is mixed with, or altered by the secretions, and,
when vomited, the material is dark brown or black, the so-called " coffee-
ground " vomit. The blood can be recognized by the microscope as shadows
of the red blood-corpuscles and irregular masses of altered blood pigment.
In cases of doubt the spectroscope may be employed or haemin crystals
obtained.
Pain, an early and important symptom, was present in 130 of our cases.
It is very variable in situation, and while most common in the epigastrium,
it may be referred to the shoulders, the back, or the loins. The pain is de-
scribed as dragging, burning, or gnawing in character, and very rarely occurs
in severe paroxysms of gastralgia, as in gastric ulcer. As a rule, the pain is
aggravated by taking food. There is usually marked tenderness on pressure
in the epigastric region. The areas of skin tenderness are referred, as Head
has shown, to the region between the nipple and the umbilicus in front and
behind from the fifth to the twelfth thoracic spine.
■ Examination of the Stomach Contents. — The vomitus in suspected
eases should be carefully studied, particularly as to quantity and character
of ingredients. Large amounts brought up at intervals of a few days, with
the appearances already described, are characteristic of dilatation of the
stomach. Some of the material should be spread in a large glass plate and
any suspicious portions picked out for examination. Bacteria in large num-
bers occur, one, the Oppler-Boas bacillus — an unusually long non-mobile form
— is supposed to be of diagnostic value, and to be largely responsible for the
formation of lactic acid. The yeast fungus is very commonly found, sarcinse
less frequently than in dilatation from stricture. Blood is a most important
ingredient; the persistent presence microscopically of red corpuscles in the
early morning washings is always very suspicious. Later, when coffee-ground
vomiting takes place, the macroscopic evidence is sufficient. In cases of doubt
the spectroscope may be used or the test made for haemin crystals. Fragments
of the new growth may be vomited or may appear in the washings. Positive
evidence of cancer may be obtained from them.
Examination of the Test BreaTcfast.—The Ewald test meal, consisting
of a slice of stale bread and a large cup of weak tea without cream or sugar,
is given at 7 a. m. and withdrawn at 8 a. m. The Boas test meal, consisting
of a gruel made of a tablespoonful of oatmeal flour in a litre of water, is
used in the estimation of lactic acid. As an outcome of the enormous num-
ber of observations made of late years, it may be said that free HCl is absent
in a large proportion of all cases of cancer of the stomach. Of 94 cases in
484 DISEASES OF THE DIGESTIVE SYSTEM.
which the contents were examined in 84 free HCl was absent. In 5 Tin-
doubted cases the reaction was good; in 3 of these the history suggested
previous ulcer. HCl may be absent in chronic gastritis and in atrophy of the
gastric mucosa. The presence of lactic acid after Boas' test meal is regarded
as a valuable sign.
Physical Examination. — Inspection. — After a preliminary survey, em-
bracing the facies, state of nutrition, etc., particular direction is given to the
abdomen. An all-important matter is to have the patient in a good light.
Fulness in the epigastric region, inequality in the infracostal grooves, the
existence of peristalsis, a wide area of aortic pulsation, the presence of sub-
cutaneous nodules or small masses about the navel, and, lastly, a well-defined
tumor mass — these, together or singly, may be seen on careful inspection.
I can not emphasize too strongly the value of this method of examination.
In 62 of the 150 cases a positive tumor could be seen. In 52 the tumor
descended with inspiration; in 36 peristalsis was visible; in 3 cases move-
ments were visible in the tumor itself. In 10 cases with visible peristalsis
no tumor was seen, but could be felt on palpation. Inflation with carbonic-
acid gas may be tried, except when hgemorrhage has been profuse or the cancer
is very extensive. The dilatation often renders evident the peristalsis or may
bring a tumor into view. The presence of subcutaneous and umbilical nodules
is sometimes a very great help. They were found in 5 of our series. Palpa-
tion.— In 115 cases a tumor could be felt; in 48 in the epigastric region, in
25 in the umbilical, in 18 in the left hypochondriac, in 17 in the right hypo-
chondriac region, while in 7 cases a mass descended in deep inspiration from
beneath the left costal margin. These figures illustrate in how large a propor-
tion of the cases the tumor is in evidence. In rare cases examination in the
knee-elbow position is of value. Mobility in gastric tumor is a point of much
importance. First, the change with respiration, already referred to; a mass
may descend 3 or 4 inches in deep inspiration; secondly, the communicated
pulsation from the aorta, which is often in its extent suggestive; thirdly, the
intrinsic movements in the hypertrophied muscularis in the neighborhood
of the cancer. This may give a remarkable character to the mass, causing
it to appear and disappear, lifting the abdominal wall in the epigastric region ;
and, fourthly, mechanical movements, with inflation, with change of posture,
or communicated with the hand. Tumors of the pylorus are the most mov-
able, and in extreme cases can be displaced to either hypochondrium or pushed
far down below the navel (see illustrative cases in my Lectures on the Diag-
nosis of Abdominal Tumors). Pain on palpation is common; the mass is
usually hard, sometimes nodular. Gas can at times be felt gurgling through
the tumor at the pyloric region.
Percussion gives less important indications — the note over a tumor is
rarely flat, more often a flat tympany. Auscultation may reveal the gurgling
through the pylorus ; sometimes a systolic bruit is transmitted f rora the aorta,
and when a local peritonitis exists a friction may be heard.
Complications. — Secondary growths are common. In 44 autopsies in our
series there were metastases in 38; in 29 the lymph-glands were involved;
in 23 the liver^ in 11 the peritonaeum, in 8 the pancreas, in 8 the bowel, in
4 the lung, in 3 the pleura, in 4 the kidneys, and in 2 the spleen. In 8 no
deposits were found.
DISEASES OF THE STOMACH. 485
Perforation may lead to peritonitis, but in 3 of our 4 cases there was no
general involvement. Cancerous ascites is not very uncommon. Dock has
called attention to the value of the examination of the fluid in such cases
as a help to diagnosis. The cells show mitoses and are very characteristic.
Secondary cancer of the liver is very common; the enlargement may be very
great, and such cases are not infrequently mistaken for primary cancer of
the organ. Involvement of the lymph-glands may give valuable indications.
There may be early enlargement of a gland at the posterior border of the
left sterno-cleido-mastoid muscle; later adjacent glands may become affected.
This occurs also in uterine cancer. According to Williams, Troisier was the
first to describe this condition, which must not be confounded with the
pseudo-lipome sus-claviculaire of Verneuil.
A very remarkable picture is presented when the cancer sloughs or be-
comes gangrenous ; the vomitus has a foul odor, often of a penetrating nature,
to be perceived throughout the room. In cases in which the ulcer perforates
the colon, the vomiting may be faecal. I have, however, met with the faecal
odor in a case with incessant vomiting ; there was no perforation of the colon
at autopsy.
Course. — ^While usually chronic and lasting from a year to eighteen
months, acute cancer of the stomach is by no means infrequent. Of the 69
cases in which we could determine accurately the duration, 15 lasted under
three months, 16 from three to six months, 14 from six to twelve months —
a total of 45 under one year. Four cases lasted for two years or over. One
case lived for at least two years and a half.
Diagnosis. — In 115 of our 150 cases a tumor existed, and with this the
recognition is rarely in doubt. Practically the chief difficulty is in those cases
which present gastric symptoms or ansemia, or both, without the presence
of tumor. In the one a chronic gastritis is suspected ; in the other a primary
anaemia. In chronic gastritis the history of long-standing dyspepsia, the ab-
sence of cachexia, the absence of lactic acid in the test meal, and the less
striking blood changes are the important points for consideration. The cases
with grave ancemia without tumor offer the greatest difficulty. The blood-
count is rarely so low as in pernicious anaemia, a point on which F. P. Henry
has laid special stress. In only 8 of our 59 cases with careful blood exami-
nation was the number below 3,000,000 per cubic millimetre. The lower
color index, as in secondary anaemia, the absence of megaloblasts, and a leuco-
cytosis speak for cancer. Some lay stress on the differential count of the
leucocytes, but there is not evidence enough to enable us to speak positively
on this point. The digestion leucocytosis might be a help in some cases.
The chemical findings are of greater value. The constant presence of lactic
acid and the absence of HCl have in several of our cases suggested the diag-
nosis of cancer, which has been verified later on by the development of a
tumor.
From ulcer of the stomach malignant disease is, as a rule, readily recog-
nized. The ulcus carcinomatosum usually presents a well-marked history of
ulcer for years. Hemmeter has given a good account of this rare condition
in his recent work on the stomach. The greatest difficulty is offered when
there is ulcer with tumor due to cicatricial contraction about the pylorus. In
3 such cases we mistook the mass for cancer, and even at operation it may
486 DISEASES OF THE DIGESTIVE SYSTEM.
(as in one of them) be impossible to say whether a neoplasm is present.
The persistent hyperchlorhydria is the most important single feature of ulcer,
and, taken with the gastralgic attacks and the haemorrhages, rarely leave doubt
as to the condition.
Nowadays, when exploratory laparotomy may be advised with such safety,
the surgeon often makes the diagnosis.
The practitioner should recognize the fact that there are cases of cancer
of the stomach in which a positive diagnosis can not be reached for weeks
or months by any known means at our command.
Treatment. — In early surgical treatment lies the only hope, but there is
great difiSculty in the diagnosis, and it would be absurd to suggest operation in
every case of dyspepsia of three months' standing in persons above forty years
of age. Operated upon early, complete removal is sometimes possible. In a
majority of cases the operation is only palliative. In suitable cases early explo-
ration should be advised ; the operation per se is sometimes beneficial and the
patient is rarely the worse for it. The diet should consist of readily digested
substances of all sorts. Many patients do best on milk alone. Washing out
the stomach, which may be done with a soft tube without any risk, is par-
ticularly advantageous when there is obstruction at the pylorus, and is by
far the most satisfactory means of combating the vomiting. The excessive
fermentation is also best treated by lavage. When the pain becomes severe,
particularly if it disturbs the rest at night, morphia must be given. One-
eighth of a grain, combined with carbonate of soda (gr. v), bismuth (gr.
v-x), usually gives prompt relief, and the dose does not always require to be
increased. Creasote (TTt j-ij) and carbolic acid are very useful. The bleed-
ing in gastric cancer is rarely amenable to treatment.
Other Forms of Tumor. — Non-cancerous tumors of the stomach rarely
cause inconvenience. Polypi (poly adenomata) are common and they may
be numerous; as many as 150 have been reported in one case. There is a
form in which the adenoma exists as an extensive area slightly raised above
the level of the mucosa — polyadenome en nappe of the French. H. B. An-
derson has described a case of remarkable multiple cysts in the walls of the
stomach and small intestine. Sarcomata are very rare. Fibromata and
lipomata have been described.
Foreign bodies occasionally produce remarkable tumors of the stomach.
The most extraordinary is the hair tumor, of which there are 16 cases in the
literature. The cases occur in hysterical women who have been in the habit
of eating their own hair. A specimen in the medical museum of McGill
University is in two sections, which form an exact mould of the stomach.
The tumors are large, very puzzling, and are usually mistaken for cancer.
Of 7 cases operated upon, 6 recovered; in 9 cases the condition was found
post mortem (Schulten).
VI. HYPERTROPHIC STENOSIS OF THE PYLORUS.
1. In Adults. — Microscopically, the condition is found to be very largely
hypertrophy of the muscularis and submucosa of the pylorus. It was well
described by the older writers. The symptoms are those of dilatation of the
stomach. The condition has been fully discussed by Boas (Archiv fiir Ver-
DISEASES OF THE STOMACH. 487
dauimgskrankheiten, Bd. 4, I), who reports two interesting cases with suc-
cessful gastro-enterostomy. The question is whether some of these cases may
not really be congenital^ as there have been instances reported in girls as
early as the twelfth and sixteenth years.
2. Congenital. — First described in 1897 by John Thomson, of Edinburgh,
much attention has been paid to this condition, which seems very common.
Still reports 20 cases (1905).
In some cases a true hyperplasia exists, but in others, as Thomson holds,
spasmodic contraction is the important factor. The diagnosis is easy — visible
peristalsis and palpable tumor.
An extraordinary number of cases have been reported within the past few
years, and of 33 operated upon 17 have recovered (Clogg, November, 1904).
Dieting, nasal feeding, and lavage should be tried before operation. In the
case of a bottle-fed baby, a wet-nurse should be obtained.
VII. HEMORRHAGE FROM THE STOMACH.
(Heematemesis.)
Etiology. — Gastrorrliagia, as this symptom is called, may result from
many conditions, local or general. 1. In local disease : (a) cancer; (&) ulcer;
(c) disease of the blood-vessels, such as miliary aneurisms and occasionally
varicose veins; (d) acute congestion, as in gastritis, and possibly in vicarious
haemorrhage; (e) following operations in the abdomen, particularly when
the omentum is wounded, erosions of the gastric mucosa may occur, from
which hsemorrhage takes place. Many cases have followed operation for
appendicitis. It is a very fatal complication, as it is usually associated with
peritonitis ( Eichardson ) .
2. Passive congestion due to obstruction in the portal system. This may
be either (a) hepatic, as in cirrhosis of the liver, thrombosis of the portal
vein, or pressure upon the portal vein by tumor, and secondarily in cases
of chronic disease of the heart and lungs; (6) splenic. Gastrorrhagia is by
no means an uncommon symptom in enlarged spleen, and is explained by the
intimate relations which exist between the vasa brevia and the splenic cir-
culation,
3. Toxic: (a) The poisons of the specific fevers, small-pox, measles, yellow
fever; (&) poisons of unknown origin, as in acute yellow atrophy and in
purpura; (c) phosphorus.
4. Traumatism: (a) Mechanical injuries, such as blows and wounds, and
occasionally by the stomach- tube ; (&) the result of severe corrosive poisons.
5. Certain constitutional diseases: (a) Haemophilia; (b) profound anae-
mias, whether idiopathic or due to splenic enlargements or to malaria; (c)
cholaemia.
6. In certain nervous affections, particularly hysteria, and occasionally
in progressive paralysis of the insane and epilepsy.
7. The blood may not always come primarily from the stomach. Thus
it may belong to the nose or the pharynx. In haemoptysis some of the blood
may find its way into the stomach. Again, in bleeding from the oesophagus
blood may trickle into the stomach, from which it is ejected. This occurs
4:SS DISEASES OF THE DIGESTIVE SYSTEM.
in the case of rapture of aneurism and of tlie oesophageal varices. A cliild
may draw blood with the milk from the mother's breast even in consideraljle
quantities and then vomit it.
8. Gastrostaxis. — Under this name Hale White describes cases of hemor-
rhage from the stomach in young girls without any lesion of the mucosa.
They are often mistaken for ulcer. He has collected 29 cases.
9. Miscellaneous causes: Aneurism of the aorta or of its branches may
rapture into the stomach. There are instances in which a patient has vom-
ited blood once without ever having a recurrence or without developing
symptoms pointing to disease of the stomach.
In new-born infants hematemesis ma}' occur alone or in connection with
bleeding from other mucous membranes.
In medical practice, haemorrhage from the stomach occurs most fre-
quently in connection with cirrhosis of the liver and ulcer of the stomach.
Morbid Anatomy. — When death has occurred from the hfematemesis there
are signs of intense ana?mia. The lesion is evident in cancer and in ulcer of
the stomach. It is to be borne in mind that fatal haemorrhage may come
from a small miliary aneurism communicating with the surface by a pin-
hole perforation, or the bleeding may be due to the rapture of a submucous
vein and the erosion in the mucosa may be small and readily overlooked.
It may require a careful and prolonged search to avoid overlooking such
lesions. In the large group associated with portal obstruction, whether due
to hepatic or splenic disease, the mucosa is usually pale, smooth, and shows
no trace of any lesion. In cirrhosis, fatal by hemorrhage, one may some-
times search in vain for any focal lesion to account for the gastrorrhagia, and
we must conclude that it is possible for even the most profuse bleeding to
occur by diapedesis. The stomach may be distended with blood and yet the
source of the haemorrhage be not apparent either in the stomach or in the
portal system. In such cases the oesophagus should be examined, as the bleed-
ing may come from that source. In toxic cases there are invariably haemor-
rhages in the mucous membrane itself.
Symptoms. — In rare instances fatal syncope may occur without any vom-
iting. In a case of the kind, in which the woman had fallen over and died
in a ie^y minutes, the stomach contained between three and four pounds of
blood. The sudden profuse bleedings rapidly lead to profound anaemia.
When due to ulcer or cirrhosis the bleeding usually recurs for several days
Fatal haemorrhage from the stomach is met with in ulcer, cirrhosis, enlarge-
ment of the spleen, and in instances in which an aneurism ruptures into the
stomach or oesophagus. Gastrorrhagia may occur in splenic anaemia or in
leukemia before the condition has aroused attention.
The vomited blood may be fluid or clotted; it is usually dark in color,
but in the basin the outer part rapidly becomes red from the action of the
air. The longer blood remains in the stomach the more altered is it when
ejected.
The amount of blood lost is very variable, and in the course of a day the
patient may bring up tliree or four pounds, or even more. In a case under
the care of George Boss, in the Montreal General Hospital, the patient lost
during seven days ten pounds, by measurement, of blood. The usual symp-
toms of anaemia develop rapidly, and there may be slight fever, and subse-
DISEASES OF THE STOMACH. 489
quently oedema may occur. Syncope, convulsions, and occasionally hemiplegia
occur after very profuse haemorrhage. Blindness may follow, the result either
of thrombosis of the retinal arteries or veins, or an acute degeneration of the
ganglion cells of the retina.
Diagnosis. — In a majority of instances there is no question as to the
origin of the blood. Occasionally it is difficult, particularly if the case has
not been seen during the attack. Examination of the vomit readily deter-
mines whether blood is present or not. The materials vomited may be stained
by wine, the juice of strawberries, raspberries, or cranberries, which give a
color very closely resembling that of fresh blood, while iron and bismuth
and bile may produce the blackish color of altered blood. In such cases the
microscope will show clearly the presence of the shadowy outlines of the red
blood-corpuscles, and, if necessary, spectroscopic and chemical tests may be
applied.
Deception is sometimes practised by hysterical patients, who swallow and
then vomit blood or colored liquids. With a little care such cases can usually
be detected. The cases must be excluded in which the blood passes from the
nose or pharynx, or in which infants swallow it with the milk.
There is not often difficulty in distinguishing between haemoptysis and
hsematemesis, though the coughing and the vomiting are not infrequently
combined. The following are points to be borne in mind in the diagnosis :
H^MATEMESIS. HEMOPTYSIS.
1. Previous history points to gas- 1. Cough or signs of some pul-
tric, hepatic, or splenic disease. monary or cardiac disease precedes,
in many cases, the haemorrhage.
2. The blood is brought up by 2. The blood is coughed up, and
.vomiting, prior to which the patient is usually preceded by a sensation of
may experience a feeling of giddiness tickling in the throat. If vomiting
or faintness. occurs, it follows the coughing.
3. The blood is usually clotted, 3. The blood is frothy, bright red
mixed with particles of food, and has in color, alkaline in reaction. If
an acid reaction. It may be dark, clotted, rarely in such large coagula,
grumous, and fluid. and muco-pus may be mixed with it.
4. Subsequent to the attack the 4. The cough persists, physical
patient passes tarry stools, and signs «igns of local disease in the chest
of disease of the abdominal viscera may usually be detected, and the
may be detected. sputa may be blood-stained for many
days.
Prognosis. — Except in the case of rupture 'of an aneurism or of large
veins, hsematemesis rarely proves fatal. In my experience death has followed
more frequently in cases of cirrhosis and splenic enlargement than in ulcer
or cancer. In ulcer it is to be remembered that in the chronic hsemorrhagic
form the bleeding may recur for years. The treatment of haematemesis is
considered under gastric ulcer.
490 DISEASES OF THE DIGESTIVE SYSTEM.
Vin. NEUROSES OF THE STOMACH.
(Nervous Dyspepsia.)
The studies of Leube, Ewald, Oser, Rosenbach, and many others have
shown that serious functional disturbances of the stomach may occur without
any discoverable anatomical basis. The cases are met with most frequently
in those who have either inherited a nervous constitution or who have gradu-
ally, through indiscretions, brought about a condition of nervous prostration.
Not infrequently, however, the gastric symptoms stand so far in the fore-
ground that the general neuropathic character of the patient quite escapes
notice. Sometimes the gastric manifestations have apparently a reflex origin
depending on organic disturbances in remote parts of the body.
The nervous derangements of the stomach may be divided into motor,
secretory, and sensory neuroses. These disturbances rarely occur singly; they
are usually met with in combined forms. The clinical picture resulting from
such a complex of gastric neuroses is known as nervous dyspepsia. As Leube
has pointed out, the sensory disturbances usually play the more important part.
The sufferer from nervous dyspepsia presents a varying picture. All
grades occur, from the emaciated skeleton-like patient with anorexia nervosa
to the well-nourished, healthy-looking, fresh-complexioned individual whose
only complaint is distress and uneasiness after eating. I have followed
Eiegel's classification.
I. Motor Neuroses. — (a)' Htpeekinesis or Supermotility. — An increase
in the normal motor activity of the stomach results in too early a discharge
of the ingesta into the intestine. It is more commonly a secondary neurosis
dependent upon superacidity or supersecretion of the gastric juice; but it
may occur primarily, possibly from reflex causes. The diagnosis is to be
reached only by means of the stomach-tube. It gives rise to no characteristic
clinical symptoms.
(&) Peristaltic Unrest. — This condition, as described by Kussmaul, is
an extremely common and distressing symptom in neurasthenia. Shortly
after eating the peristaltic movements of the stomach are increased, and
borborygmi and gurgling may be heard, even at a distance. The subjective
sensations are most annoying, and it would appear as if in the hypergesthetic
condition of the nervous system the patient felt normal peristalsis, just as in
these states the usual beating of the heart may be perceptible to him. A
further analogy is afforded by the fact that emotion increases this peristalsis.
It may extend to the intestines, particularly to the duodenum, and on palpa-
tion over this region the gurgling is most marked. The movement may be
anti-peristalsis, in which the wave passes from right to left, a condition which
may also extend to the intestines. There are cases on record in which colored
enemata or even scybala have been discharged from the mouth.
(c) jSTervous Eructations. — Aerophagia. — In this condition severe attacks
of noisy eructations, following one another often in rapid succession, occur.
When violent they last for hours or days. At other times they occur in parox-
ysms, depending often upon mental excitement. They are more commonly
observed in hysterical women and neurasthenics, but also, not infrequently.
DISEASES OF THE STOMACH. 491
in children. The hysterical nature of the affection is sometimes testified
to by the occurrence, especially in children, of several instances in one
household.
The expelled gas in these cases is atmospheric air, which is swallowed or
aspirated from without. Sometimes the whole process may be clearly ob-
served, but in other instances the act of swallowing may be almost or quite
imperceptible. Bouveret considers the condition due to a spasm of the phar-
ynx which causes involuntary swallowing. Oser has suggested that the air
may enter by aspiration, the stomach acting like an elastic rubber bag which
tends to fill again after the air is expressed. It is quite possible that in some
instances the eructations consist of gas which has never actually reached the
stomach, but is brought up from the oesophagus.
(d) Nervous Vomiting. — A condition which is not associated with ana-
tomical changes in the stomach or with any state of the contents, but is due
to nervous influences acting either directly or indirectly upon the centres
presiding over the act of vomiting. The patients are, as a rule, women — •
usually brunettes — and the subject of more or less marked hysterical mani-
festations. A special feature of this form is the absence of the preliminary
nausea and of the straining efforts of the ordinary act of vomiting. It is
rather a regurgitation, and without visible effort and without gagging the
mouth is filled with the contents of the stomach, which are then spat out.
It comes on, as a rule, after eating, but may occur at irregular intervals. In
some eases the nutrition is not impaired, a feature which may give a clew to
the true nature of the disease, as there may be no other hysterical manifesta-
tion present. As noted by Tuckwell, it may occur in children, and Edsall
suggests that this recurring vomiting is an acid intoxication, as in some eases
acetone and diacetic acid have been found in the urine. Treatment with full
doses of 20 grains of bicarbonate of soda every two hours has been found to
relieve it. Nervous vomiting may be a very serious condition. We have had
at least two fatal cases. In some instances, after persisting for weeks or months
at home the patient gets well in a few days in hospital. In other instances the
course is protracted, and the cases are among the most trying we are called
upon to treat.
A type of vomiting is that associated with certain diseases of the nervous
system — particularly locomotor ataxia — forming part of the gastric crises,
Leyden has reported cases of primary periodic vomiting, which he regards
as a neurosis.
(e) Rumination; Mertcismus. — In this remarkable and rare condition
the patients regurgitate and chew the cud like ruminants. It occurs in neuras-
thenic or hysterical persons, epileptics, and idiots. In some patients it is
hereditary. There is an instance in which a governess taught it to two chil-
dren. The habit may persist for years, and does not necessarily impair the
health.
(f) Spasm of the Cardia. — Spasmodic, usually painful contraction of
the circular muscle fibres at the cardiac orifice may follow the introduction
of a sound, hasty eating, or the taking of too hot or too cold food. It may
occur in tetanus and also in hysterical and neurasthenic individuals, especially
in air swallowers, in whom, if it be combined with pyloric spasm, it may
result in painful gastric distention — " pneumatosis.^' Here the spasm may
492 DISEASES OF THE DIGESTIVE SYSTEM.
be of considerable duration. The condition is rare and practically not of
much moment.
(g) Pyloeic Spasm. — This is usually a secondary occurrence, following
superacidity, supersecretion, ulcer, or the introduction into the stomach of
irritating substances. The spasm often causes pain in the region of the
pylorus and increased gastric peristalsis. In cases where the spasm is com-
bined with superacidity and supersecretion marked dilatation with atony may
follow; it is questionable, however, whether a primary nervous pyloric spasm
ever gives rise to serious results.
(h) Atony of the Stomach, — Motor insufficiency of the stomach is gen-
erally due to injudicious feeding, to organic disease of the stomach itself, or
to general wasting processes. In some otherwise normal individuals of neu-
rotic temperaments an atony may, however, occur which possibly deserves to
be classed among the neuroses. The symptoms are usually those of a moderate
dilatation, and are often associated with marked sensory disturbances — feel-
ings of weight and pressure, distention, eructations, and so forth.
Great care must be taken in the diagnosis to rule out all other possible
causes.
(t) Insufficiency or Incontinence of the Pyloeus. — This condition
was described first by de Sere and later by Ebstein, It may be recognized by
the rapid passing of gas from the stomach into the bowel on attempts at
inflation of the former, as well as by the presence of bile and intestinal con-
tents in the stomach. There are no distinctive clinical symptoms.
(;') Insufficiency of the Caedia. — This condition is only recognized by
the occurrence of eructations or in rumination.
II. Secretory Neuroses. — (a) Hyperacidity; Superacidity; Hyper-
CHLOEHYDEiA. — Ncrvous dyspepsia with hyperacidity of the gastric juices.
The symptoms depend upon the secretion of an abnormally acid gastric juice
at the time of digestion. This is a common form of dyspepsia in young and
neurotic individuals. Oswald has pointed out its remarkable frequency in
chlorotic girls. The sjanptoms are very variable. They do not, as a rule,
immediately follow the ingestion of food, but occur one to three hours later,
at the height of digestion. There is a sense of weight and pressure, some-
times of burning in the epigastrium, commonly associated with acid eructa-
tions. - If vomiting occurs, the pain is relieved. The patient is usually rela-
tively well nourished, and the appetite is often good, though the sufferer may
be afraid to eat on account of the anticipated pain. Its association with ulcer
has been referred to. There is commonly constipation.
(&) Supeeseceetion, Inteemittent and Continuous. — This is a form
of dyspepsia which has been long recognized, but of late has been specially
studied by Eeichmann and others. The increased flow of the gastric juice
may be intermittent or continuous. The secretion under such circumstances
is usually superacid, though this is not always the case. The periodical form
— the gastroxynsis of Eossbach — may be quite independent of the time of
digestion. Great quantities of highly acid gastric juice may be secreted in
a very small space of time. Such cases are rare, and are especially associated
either with profound neurasthenia or with locomotor ataxia. The attack may
last for several days. It usually sets in with a gnawing, unpleasant sensation
in the stomach, severe headache, and shortly after the patient vomits a clear,
DISEASES OF THE STOMACH. 493
watery secretion of such acidity that the throat is irritated and made raw and
sore. As mentioned, the attacks may be quite independent of food. Con-
tinuous supersecretion is more common. The constant presence of fluid in
the stomach, together with the pyloric spasm, which commonly results from
the irritation of the overacid gastric juice, are followed by a more or less
extensive dilatation. Digestion of the starches is retarded, and there are
eructations of acid fluid and gastric distress. This secretion of highly acid
gastric juice may continue when the stomach is free from food. In these
cases pain, burning acid eructations, and even vomiting, occurring during the
night and early in the morning, are rather characteristic.
(c) Nervous Subacidity or Inacidity; Achylia Gastrica Nervosa. —
Lack of the normal amount of acid is found in chronic catarrh, and particu-
larly in cancer. As Leube has shown, a reduction in the normal amount of
acid may exist with the most pronounced symptoms of nervous dyspepsia and
yet the stomach will be free from food within the regular time. A condition
in which free acid is absent in the gastric juice may occur in cancer, in ex-
treme sclerosis of the mucous membrane, as a nervous manifestation of hysteria,
and occasionally of tabes. In most of these cases, though there be no free
acid, yet the other digestive ferments — pepsin and the curdling ferments —
or their zymogens are to be demonstrated in the gastric juice. There may,
however, be a complete absence of the gastric secretion. To these cases Ein-
horn has given the name of achylia gastrica. This condition was' at first
thought to occur only in cases of total atrophy of the gastric mucosa, but
recent observations have shown that it may occur as a neurosis. In a case
of Einhorn's the gastric secretions returned after five years of total achylia
gastrica.
The symptoms of subacidity, or even of achylia gastrica, vary greatly in
intensity; they may be almost or quite absent in cases of advanced atrophy of
the mucosa, and, as a rule, are not marked so long as the -motor activity
of the stomach remains good. If atony, however, occur and abnormal fer-
mentative processes arise, severe gastric and intestinal symptoms may follow.
In the cases associated with hysteria and neurasthenia, even though the food
may be well taken care of by the intestines, there are very commonly grave
sensory disturbances in the region of the stomach, in addition to the general
nervous symptoms.
III. Sensory Neuroses. — (a) Hyperesthesia. — In this condition the pa-
-^tients complain of fulness, pressure, weight, burning, and so forth, during
digestion, just such symptoms as accompany a variety of organic diseases of
the stomach, and yet in all other respects the gastric functions appear quite
normal. Sometimes these distressing sensations are present even when the
stomach is empty. These symptoms are usually associated with other mani-
festations of hysteria and neurasthenia. The pain often follows particular
articles of food. An hysterical patient may apparently sufEer excruciating pain
after taking the smallest amount of food of any sort, while anything pre-
scribed as a medicine may be well borne. In severe cases the patient may be
reduced to an extreme degree by starvation.
(b) Gastralgia ; Gastrodynia. — Severe pains in the epigastrium, parox-
ysmal in character, occur (1) as a manifestation of a functional neurosis, in-
dependent of organic disease, and usually associated with other nervous symp-
494 DISEASES OF THE DIGESTIVE SYSTEM.
toms (it is this form which will here be described) ; (3) in chronic disease
of the nervous system, forming the so-called gastric crises; and (3) in organic
disease of the stomach, such as ulcer or cancer.
The functional neurosis occurs chiefly in women, very commonly in con-
nection with disturbed menstrual function or with pronounced hysterical symp-
toms. The affection may set in as early as puberty, but it is more common at
the menopause. Anaemic, constipated women who have worries and anxieties
at home are most prone to the affection. It is more frequent in brunettes than
in blondes. Attacks of it sometimes occur in robust, healthy men. More
often it is only one feature in a condition of general neurasthenia or a mani-
festation of that form of nervous dyspepsia in which the gastric juice or
hydrochloric acid is secreted in excess. I am very sceptical as to the existence
of a gastralgia of purely malarial origin.
The symptoms are very characteristic; the patient is suddenly seized with
agonizing pains in the. epigastrium, which pass toward the back and around
the lower ribs. The attack is usually independent of the taking of food, and
may recur at definite intervals, a periodicity which has given rise to the sup-
position in some cases that the affection is due to malaria. The most marked
periodicity, however, may be in the gastralgic attacks of ulcer. They fre-
quently come on at night. Vomiting is rare; more commonly the taking of
food relieves the pain. To this, however, there are striking exceptions. Pres-
sure upon the epigastrium commonly gives relief, but deep pressure may be
painful. It seems scarcely necessary to separate the forms, as some have done,
into irritative and depressive, as the cases insensibly merge into each other.
Stress has been laid upon the occurrence of painful points, but they are so
common in neurasthenia that very little importance can be attributed to them.
The diagnosis offers many difficulties. Organic disease either of the stom-
ach or of the nervous system, particularly the gastric crises of locomotor
ataxia, must be excluded. In the case of ulcer or cancer this is not always
easy. The fact that the pain is most marked when the stomach is empty and
is relieved by the taking of food is sometimes regarded as pathognomonic of
simple gastralgia, but to this there are many exceptions, and in cancer the
pains may be relieved on eating. The prolonged intervals between the attacks
and their independence of diet are important features in simple gastralgia;
but in many instances it is less the local than the general symptoms of the
case which enable us to make the diagnosis. In gall-stone colic jaundice is
frequently absent, and in any long-standing case of gastralgia, in which the
attacks recur at intervals for years, the question of cholelithiasis should be
considered. There may be hyperacidity associated with gastric atony. In one
such case recently we treated the case for weeks as one of painful nervous
dyspepsia until a more severe attack than usual was followed by jaundice. At
the same time, there was a neurotic physician in the hospital who had had
recurring attacks of abdominal pain of the greatest severity, and once, he
said, with jaundice. At operation his gall-bladder was normal !
(c) Anomalies of the Sense of Hunger and Eepletion; Bulimia. —
Abnormally excessive hunger coming on often in paroxysmal attacks, which
cause the patient to commit extraordinary excesses in eating. This condition
may occur in diabetes mellitus and sometimes in gastric disorders, particularly
those associated with supersecretion. It is, however, more commonly seen in
DISEASES OF THE STOMACH. 495
hysteria and in psyclioses. It may occur in cerebral tumors, in Graves' dis-
ease, and in epilepsy.
The attacks often begin suddenly at night, the patient waking with a
feeling of faintness and pain, and an uncontrollable desire for food. Some-
times such attacks occur immediately after a large meal. The attack may
be relieved by a small amount of food, while at other times enormous quan-
tities may be taken. In obstinate cases gastritis, atony, and dilatation fre-
quently result from the abuse of the stomach.
Ahoria. — An absence of the sense of satiety. This condition is commonly
associated with bulimia and polyphagia, but not always. The patient always
feels " empty." There are usually other well-marked manifestations of hys-
teria or neurasthenia.
Anorexia Nervosa. — This condition, which is a manifestation of a neurotic
temperament, is discussed subsequently under the general heading of Hysteria.
Treatment of Neuroses of the Stomach. — The most important part of the
treatment of nervous dyspepsia is often that directed toward the improvement
of the general physical and mental condition of the patient. The possibility
that the symptoms may be of reflex origin should be borne in mind. A large
proportion of cases of nervous dyspepsia are dependent upon mental and physi-
cal exhaustion or worry, and a vacation or a change of scene will often accom-
plish what years of. treatment at home have failed to do. The manner of life
of the patient should be investigated and a proper amount of physical exercise
in the open air insisted upon. This alone will in some cases be sufficient to
cause the disappearance of the s5^mptoms.
Many cases of nervous dyspepsia with marked neurasthenic or hysterical
symptoms do well on the Weir Mitchell treatment, and in obstinate forms it
should be given a thorough trial. The most striking results are perhaps seen
in the case of anorexia nervosa, which will be referred to subsequently. It is
also of value in nervous vomiting.
In cardiac ^pasm care should be taken to eat slowly, to avoid swallowing
too large morsels or irritating substances. The methodical introduction of
thick sounds may be of value.
The treatment in atony of the stomach should be similar to that adopted
in moderate dilatation — the administration of small quantities of food at
frequent intervals; the limitation of the fluids, which should also be taken
in small amounts at a time ; lavage. Strychnine in full doses may be of value.
In the distressing cases of hyperacidity, in addition to the treatment of
the general neurotic condition, alkalies must be employed either in the form
of magnesia or bicarbonate of soda. These should be given in large doses
and at the height of digestion. The burning acid eructations may be re-
lieved in this way. The diet should be mainly albuminous, and should be
administered in a non-irritating form. Stimulating condiments and alcohol
should be avoided. Starches should be sparingly allowed, and only in most
digestible forms. Fats are fairly well borne.
Limiting the patient to a strictly meat diet is a valuable procedure in many
cases of dyspepsia associated with hyperacidity. The meat should be taken
either raw or, if an insuperable objection exists to this, very slightly cooked.
It is best given finely minced or grated on stale bread. An ample dietary is
3:| ounces (100 grammes) of meat, two medium slices of stale bread, and an
496 DISEASES OF THE DIGESTIVE SYSTEM.
ounce (30 grammes) of butter. This may be taken three times a day with
a glass of Apollinaris water, soda water, or, what is just as satisfactory, spring
water. The fluid should not be taken too cold. Special care should be taken
in the examination of the meat to guard against tape-worm infection, but
suitable instructions on this point can be given. This is suiBcient for an
adult man, and many obstinate cases yield satisfactorily to a month or six
weeks of this treatment, after which time the less readily digested articles of
food may be gradually added to the dietary.
In supersecretion the use of the stomach-tube is of the greatest value. In
the periodical form it should be used as soon as the attack begins. The
stomach may be washed with alkaline solutions or solutions of nitrate of
silver, 1 to 1,000, may be used. Where this is impracticable the taking of
albuminous food may give relief. One of my patients used to have by his
bedside two hard-boiled eggs, by the eating of which nocturnal attacks were
alleviated. Alkalies in large doses are also indicated.
In cases of continued supersecretion there is usually atony and dilatation.
The diet here should be much as in superacidity, but should be administered
in smaller quantities at frequent intervals. Lavage with alkaline solutions
or with nitrate of silver is of great value. To relieve pain large quantities of
bicarbonate of soda or magnesia should be 'given at the height of digestion.
In suh acidity a carefully regulated, easily digestible mixed diet, not too
rich in albuminoids, is advisable. Bitter tonics before meals are sometimes
of value. In acliylia gastrica the use of predigested foods and of hydrochloric
acid in full doses may be of assistance.
In marked hypercesthesia, beside the treatment of the general condition,
nitrate of silver in doses of gr. -J-J, taken in § iij-o iv of water on an empty
stomach, is advised by Rosenheim.
In some instances rectal feeding may have to be resorted to.
The gastralgia, if very severe, requires morphia, which is best adminis-
tered subcutaneously in combination with atropia. In the milder attacks the
combination of morphia (gr. |) with cocaine and belladonna is recommended
by Ewald. The greatest caution should, however, be exercised in these cases
in the use of the hypodermic syringe. It is preferable, if opium is necessary,
to give it by the mouth, and not to let the patient know the character of the
drug. Chloroform, in from 10- to 20-drop doses, or Hoffman's anodyne will
sometimes allay the severe pains. The general condition should receive careful
attention, and in many cases the attacks recur until the health is restored by
change of air with the prolonged use of arsenic. If there is anaemia iron may
be given freely. Nitrate of silver in doses of gr. ^ to ^ in a large claret-glass
of water taken on an empty stomach is useful in some cases.
There are forms of nervous dyspepsia occurring in women who are often
well nourished and with a good color, yet who suffer — ^particularly at night —
with flatulency and abdominal distress. The sleep may be quiet and undis-
turbed for two or three hours, after which they are aroused with painful
sensations in the abdomen and eructations. The appetite and digestion may
appear to be normal. Constipation is, however, usually present. In many
of these patients the condition seems rather intestinal dyspepsia, and the
distress is due to the accumulation of gases, the result of excessive putrefac-
tion. The fats, starches, and sugars should be restricted. A diastase ferment
DISEASES OF THE INTESTINES. 497
is sometimes useful. The flatulency may be treated by the methods above
mentioned. Naphthalin, salicylate of bismuth, and salol have been recom-
mended. Some of these cases obtain relief from thorough irrigation of the
colon at bedtime.
The treatment of anorexia nervosa is described subsequently.
G. DISEASES OF THE INTESTINES.
I. DISEASES OF THE INTESTINES ASSOCIATED
WITH DIARRHCEA.
Catarrhal Enteritis; Diarrhcea.
In the classification of catarrhal enteritis the anatomical divisions of the
bowel have been too closely followed, and a duodenitis, jejunitis, ileitis, typhli-
tis, colitis, and proctitis have been recognized ; whereas in a majority of cases
the entire intestinal tract, to a greater or lesser extent, is involved, sometimes
the small most intensely, sometimes the large bowel: but during life it may
be quite impossible to say which portion is specially affected.
Etiology. — The causes may be either primary or secondary. Among the
causes of primary catarrhal enteritis are : (a) Improper food, one of the most
frequent, especially in children, in whom it follows overeating, or the ingestion
of unripe fruit. In some individuals special articles of diet will always pro-
duce a slight diarrhoea, which may not be due to a catarrh of the mucosa, but
to increased peristalsis induced by the offending material. (&) Various toxic
substances. Many of the organic poisons, such as those produced in the de-
composition of milk and articles of food, excite the most intense intestinal
catarrh. Certain inorganic substances, as arsenic and mercury, act in the
same way. (c) Changes in the weather. A fall in the temperature of from
twenty to thirty degrees, particularly in the spring or autumn, may induce —
how, it is difficult to say — an acute diarrhoea. We speak of this as a catarrhal
process, the result of cold or of chill. On the other hand, the diarrhoeal dis-
eases of children are associated in a very special way with the excessive heat
of summer months, (d) Changes in the constitution of the intestinal secre-
tions. We know too little about the succus entericus to be able to speak of
influences induced by change in its quantity or quality. It has long been
held that an increase in the amount of bile poured into the bowel might excite
a diarrhoea ; hence the term bilious diarrhoea, so frequently used by the older
writers. Possibly there are conditions in which an excessive amount of bile
is poured into the intestine, increasing the peristalsis, and hurrying on the
contents; but the opposite state, a scanty secretion, by favoring the natural
fermentative processes, much more commonly causes an intestinal catarrh.
Absence of the pancreatic secretion from the intestine has been associated in
certain cases with a fatty diarrhoea, (e) Nervous influences. It is by no
means clear how mental states act upon the bowels, and yet it is an old and
trustworthy observation, which every-day experience confirms, that the mental
state may profoundly affect the intestinal canal. These influences should not
properly be considered under catarrhal processes, as they result simply from
33
498 DISEASES OF THE DIGESTIVE SYSTEM.
increased peristalsis or increased secretion, and are usually described under
the heading nervous diarrhwa. In children it frequently follows fright. It is
common, too, in adults as a result of emotional disturbances. Cahstatt men-
tions a surgeon who always before an important operation had watery diar-
rhoea. In hysterical women it is seen as an occasional occurrence, due to
transient excitement, or as a chronic^, protracted diarrhoea, which may last
for months or even years.
Among the secondary causes of intestinal catarrh may be mentioned : (a)
Infectious diseases. Dysentery, cholera, typhoid fever, pyaemia, septicaemia,
tuberculosis, and pneumonia are occasionally associated with intestinal catarrh.
In dysentery and typhoid fever the ulceration is in part responsible for the
catarrhal condition, but in cholera it is probably a direct influence of the
bacilli or of the toxic materials produced by them. (&) The extension of
inflammatory processes from adjacent parts. Thus, in peritonitis, catarrhal
swelling and increased secretion are always present in the mucosa. In cases
of invagination, hernia, tuberculous or cancerous ulceration, catarrhal proc-
esses are common, (c) Circulatory disturbances cause a catarrhal enteritis,
usually of a very chronic character. This is common in diseases of the liver,
such as cirrhosis, and in chronic affections of the heart and lungs — all condi-
tions, in fact, which produce engorgement of the terminal branches of the
portal vessels, (d) In the cachectic conditions met with in cancer, profound
anaemia, Addison's disease, and Bright's disease intestinal catarrh may occur
as a terminal event.
Morbid Anatomy. — Changes in the mucous membrane are not always visi-
ble, and in cases in which, during life, the symptoms of intestinal catarrh
have been marked, neither redness, swelling, nor increased secretion — the three
signs usually laid down as characteristic of catarrhal inflammation — ^may be
present post mortem. It is rare to see the mucous membrane injected; more
commonly it is pale and covered with mucus. In the upper part of the small
intestine the tips of the valvulee conniventes may be deeply injected. Even in
extreme grades of portal obstruction intense hyperaemia is not often seen.
The entire mucosa may be softened and infiltrated, the lining epithelium
swollen, or even shed, and appearing as large flakes among the intestinal
contents. This is, no doubt, a post-mortem change. The lymph follicles are
almost always swollen, particularly in children. The Peyers patches may
be prominent and the solitary follicles in the large and small bowel ,may stand
out with distinctness and present in the centres little erosions, the so-called
follicular ulcers. This may be a striking feature in the intestine in all forms
of catarrhal enteritis in cliildren, quite irrespective of the intensity of the
diarrhoea.
When the process is more chronic the mucosa is flrmer, in some instances
thickened, in others distinctly thinned, and the villi and follicles present a
slaty pigmentation.
Symptoms. — Acute and chronic forms may be recognized. The important
symptom of both is diarrhoea, which, in the majority of instances, is the sole
indication of this condition. It is not to be supposed that diarrhoea is invari-
ably caused by, or associated with, catarrhal enteritis, as it may be produced
by nervous and other influences. It is probable that catarrh of the jejunum
may exist without any diarrhoea; indeed, it is a very common circumstance
DISEASES OF THE INTESTINES. 499
to find post mortem a catarrhal state of the small bowel in persons who have
not had diarrhoea during life. The stools vary extremely in character. The
color depends upon the amount of bile with which they are mixed, and they
may be of a dark or blackish brown, or of a light -yellow, or even of a grayish-
white tint. The consistence is usually very thin and watery, but in some
instances the stools are pultaceous like thin gruel. Portions of undigested
food can often be seen (lienteric diarrhoea), and flakes of yellowish-brown
mucus. Microscopically there are innumerable micro-organisms, epithelium
and mucous cells, crystals of phosphate of lime, oxalate of lime, and occasion-
ally cholesterin and Charcot's crystals.
Pain in the abdomen is usually present in the acute catarrhal enteritis,
particularly when due to food. It is of a colicky character, and when the
colon is involved there may be tenesmus. More or less tympanites exists, and
there are gurgling noises or borborygmi, due to the rapid passage of fluid and
gas from one part to another. In the very acute attacks there may be vomit-
ing. Fever is not, as a rule, present, but there may be a slight elevation of
one or two degrees. The appetite is lost, there is intense thirst, and the
tongue is dry and coated. In very acute cases, when the quantity of fluid
lost is great and the pain excessive, there may be collapse symptoms. The
number of evacuations varies from four or five to twenty or more in the
course of the day. The attack lasts for two or three days, or may be prolonged
for a week or ten days.
Chronic catarrh of the bowels may follow the acute form, or may come on
gradually as an independent affection or as a sequence of obstruction in the
portal circulation. It is characterized by diarrhoea, with or without colic.
The dejections vary; when the small bowel is chiefly involved the diarrhoea
is of a lienteric character, and when the colon is affected the stools are thin
and mixed with much mucus. A special form of mucous diarrhoea will be
subsequently described. The general nutrition in these chronic cases is
greatly disturbed; there may be much loss of flesh and great pallor. The
patients are inclined to suffer from low spirits, or hypochondriasis may develop.
Diagnosis. — It is important, in the first place, to determine, if possible,
whether the large or small bowel is chiefly affected. In catarrh of the small
bowel the diarrhoea is less marked, the pains are of a colicky character, bor-
borygmi are not so frequent, the faeces usually contain portions of food, and
are more yellowish-green or grayish-yellow and flocculent and do not contain
much mucus. When the large intestine is at fault there may be no pain
whatever, as in the catarrh of the large intestine associated with tuberculosis
and Bright's disease. When present, the pains are most intense and, if the
lower portion of the bowel is involved, there may be marked tenesmus. The
stools have a uniform soupy consistence ; they are grayish in color and granu-
lar throughout, with here and thei:e flakes of mucus, or they may contain
very large quantities of mucus.
There are no positive symptoms by which the diagnosis of duodenitis can
be made. It is usually associated with acute gastritis and, if the process
extends into the bile-duct, with jaundice. Neither jejunitis nor ileitis can
be separated from general intestinal catarrh.
The Cceliac Affection. — Under this heading Gee has described an intestinal
disorder, most commonly met with in children between the ages of one and
500 DISEASES OF THE DIGESTIVE SYSTEM.
five, characterized by the occurrence of pale, loose stools, not unlike gruel or
oatmeal porridge. They are bulky, not watery, yeasty, frothy, and extremely
offensive. The affection has received various names, such as diarrhoea alia or
diarrhcea cliylosa. It is not associated with tuberculous or other hereditary
disease. It begins insidiously and there are progressive wasting, weakness,
and pallor. The belly becomes doughy and inelastic. There is often flatu-
lency. Fever is usually absent. The disease is lingering and a fatal termina-
tion is common. So far nothing is known of the pathology of the disease.
Ulceration of the intestines has been met with, but it is not constant.
Sprue or Psilosis. — A remarkable disease of the tropics, characterized by
" a peculiar, inflamed, superficially ulcerated, exceedingly sensitive condition,
of the mucous membrane of the tongue and mouth; great wasting and anae-
mia; pale, copious, and often loose, frequent, and frothy fermenting stools;
very generally by more or less diarrhoea; and also by a marked tendency to
relapse '' ( Manson ) .
It is very prevalent in India, Chiaa, and Java. i«[othuig definite is known
as to its cause.
AYhen fully established the chief s}Taptoms are a disturbed condition of
the bowels, pale, yeasty-looking stools, a raw, bare, sore condition of the
tongue, mouth, and gullet, sometimes with actual superficial ulceration. With
these gastro-intestinal s3'mptoms there are associated ansemia and general wast-
ing. It is very chronic 'oith numerous relapses. There are no characteristic
anatomical changes. There are usually ulcers in the colon, and the French
think it is a form of dysentery.
]\Ianson recommends rest and a milk diet as curative in a large proportion
of the cases. The monograph by Thin and the article by Manson ui Allbutt's
System give very full descriptions of the disease.
DiPHTHEEITIC OE CROUPOUS ENTEEITIS.
A croupous or diphtheritic inflammation of the mucosa of the small and
large intestines occurs (a) most frequently as a secondary process in the
infectious diseases — pneumonia, pyaemia in its various forms, and tA^phoid
fever; (&) as a terminal process in many chronic affections, such as Bright' s
disease, cirrhosis of the liver, or cancer; and (c) as an effect of certain poisons
— mercury, lead, and arsenic.
There are three different anatomical pictures. In one group of cases the
mucosa presents on the top of the folds a thin grayish-yellow diphtheritic
exudate situated upon a deeply congested base. In some cases all grades may
be seen between the thinnest fllm of superficial necrosis and involvement of
the entire thickness of the mucosa. In the colon similar transversely arranged
areas of necrosis are seen situated upon h}^er8smic patches, and it may be
here much more extensive and involve a large portion of the membrane. There
may be most extensive inflammation without any involvement of the solitary
follicles of the large or small bowel.
In a second group of cases the membrane has rather a croupous character.
It is grayish-white in color, more flake-like and extensive, limited, perhaps,
to the cascum or to a portion of the colon; thus, in several. cases of pneumonia
I found this flaky adherent false membrane, in one instance forming patches
1 to 2 cm. in diameter, which in form were not unlike rupia crusts.
DISEASES OF THE INTESTINES. 501
In a third group the affection is really a follicular enteritis^ involving the
solitary glands, which are swollen and capped with an area of diphtheritic
necrosis or are in a state of suppuration. Follicular ulcers are common in this
form. The disease may run its course without any symptoms, and the condi-
tion is unexpectedly met with post mortem. In other instances there are
diarrhoea, pain, but not often tenesmus or the passage of blood-stained mucus.
In the toxic cases the intestinal symptoms may be very marked, but in the
terminal colitis of the fevers and of constitutional affections the symptoms
are often trifling.
The ulcerative colitis of chronic disease may be only a terminal event in
these diphtheritic processes.
Phlegmonous Enteritis.
As an independent affection this is excessively rare, even less frequent
than its counterpart in the stomach. It is seen occasionally in connection
with intussusception, strangulated hernia, and chronic obstruction. Apart
from these conditions it occurs most frequently in the duodenum, and leads
to suppuration in the submucosa and abscess formation. Except when asso-
ciated with hernia or intussusception the affection can not be diagnosed. The
symptoms usually resemble those of peritonitis.
Ulcerative Enteritis.
In addition to the specific ulcers of tuberculosis, syphilis, and typhoid
fever, the following forms of ulceration occur in the bowels :
(a) Follicular Ulceration. — As previously mentioned, this is met with very
commonly in the diarrhceal diseases of children, and also in the secondary
or terminal inflammations in many fevers and constitutional disorders. The
ulcers are small, punched out, with sharply cut edges, and they are usually
limited to the follicles. With this form may be placed the catarrhal ulcers
of some writers.
(&) Stercoral ulcers, which occur in long standing cases of constipation.
Very remarkable indeed are the cases in which the sacculi of the colon become
filled with rounded small scybala, some of which produce distinct ulcers in
the mucous membrane. The fsecal masses may have lime salts deposited in
them, and thus form little enteroliths.
(c) Simple Ulcerative Colitis. — This affection, which clinically is charac-
terized by diarrhoea, is often regarded wrongly as a form of dysentery. It is
not a very uncommon affection, and is most frequently met with in men
above the middle period of life. The ulceration may be very extensive, so
that a large proportion of the mucosa is removed. The lumen of the colon
is sometimes greatly increased, and the muscular walls hypertrophied. There
are instances in which the bowel is contracted. Frequently the remnants of
the mucosa are very dark, even black, and there may be polypoid outgrowths
between the ulcers.
These cases rarely come under observation at the outset, and it is difficult
to speak of the mode of origin. They are characterized by diarrhoea of a
lienteric rather than of a dysenteric character. There is rarely blood or pus
in the stools. Constipation may alternate with the diarrhoea. There is usu-
502 DISEASES OF THE DIGESTIVE SYSTEM.
ally great impairment of nutrition^ and the patients get weak and sallow.
Perforation occasional!}^ occurs.
The disease ma}' prove fatal, or it may pass on and become chronic. The
affection was not very infrequent at the Philadelphia Hospital, and though
the disease bears some resemblance to dysentery, it is to be separated from it.
Some of the cases which we have learned to recognize as amoebic dysentery
resemble this form very closely. An excellent description of it is given by
Hale White in Allbutt's System. The ulcerative colitis met with in institu-
tions, such as that described by Gemmel, of the Lancaster Asylum, seems to
be a true dysentery. Dickinson has described what he calls albuminuric ulcera-
tion of the bowels in cases of contracted kidney.
(d) TJlceration from External Perforation. — This may result from the
erosion of new growths or, more commonly, from localized peritonitis with
abscess formation and perforation of the bowel. This is met with most fre-
quently in tuberculous peritonitis, but it may occur in the abscess which
follows perforation of the appendix or suppurative or gangrenous pancreatitis.
Fatal hemorrhage may result from the perforation.
(e) Cancerous TTlcers. — In very rare instances of multiple cancer or sar-
coma the submucous nodules break down and ulcerate. In one case the ileum
contained eight or ten sarcomatous ulcers secondary to an extensive sarcoma
in the neighborhood of the shoulder-joint.
(/) Occasionally a solitary nicer is met with in the caecum or colon, which
may lead to perforation. Two instances of ulcer of the caecum, both with
perforation, have come under my observation, and in one instance a simple
ulcer of the colon perforated and led to fatal peritonitis.
Diagnosis of Intestinal Ulcers. — As a rule, diarrhoea is present in all cases,
but exceptionally there may be extensive ulceration, particularly in the small
bowel, without diarrhoea. Very limited ulceration in the colon may be asso-
ciated with frequent stools. The character of the dejections is of great im-
portance. Pus, shreds of tissue, and blood are the most valuable indications.
Pus occurs most frequently in connection with ulcers in the large intestine,
but when the bowel alone is involved the amount is rarely great, and the
passage of any quantity of pure pus is an indication that it has come from
without, most commonly from the rupture of a pericaecal abscess, or in women
of an abscess of the broad ligament. Pus may also be present in cancer of
the bowel, or it may be due to local disease in the rectum. A purulent mucus
may be present in the stools in cases of ulcer, but it has not the same diag-
nostic value. The swollen, sago-like masses of mucus which are believed by
some to indicate follicular ulceration are met with also in mucous colitis.
Hsemorrhage is an important and valuable s}Tnptom of ulcer of the bowel,
particularly if profuse. It occurs under so many conditions that taken alone
it may not be specially significant, but with other coexisting circumstances
it may be the most important indication of all.
Fragments of tissue are occasionally found in the stools in ulcer, particu-
larly in the extensive and rapid sloughing in dysenteric processes. Definite
portions of mucosa, shreds of connective tissue, and even bits of the muscular
coat may be found. Pain occurs in many cases, either of a diffuse, colicky
character, or sometimes, in the ulcer of the colon, very limited and well
defined.
DISEASES OF THE INTESTINES. 503
Perforation is an accident liable to happen when the ulcer extends deeply.
In the small bowel it leads to a localized or general peritonitis. In the large
intestine, too, a fatal peritonitis may result, or if perforation takes place -in
the posterior wall of the ascending or descending colon, the production of a
large abscess cavity in the retro-peritongeum. In a case at the University Hos-
pital, Philadelphia, there was a perforation at the splenic flexure of the colon
with an abscess containing air and pus — a condition of subphrenic pyo-pneu-
mothorax.
Treatment of the Previous Conditions.
(a) Acute Dyspeptic DiarrhcEa. — All solid food should be withheld. If
vomiting is present ice may be given, and small quantities of milk and soda
water may be taken. If the attack has followed the eating of large quanti-
ties of indigestible material, castor oil or calomel is advisable, but is not neces-
sary if the patient has been freely purged. If the pain is severe, 20 drops
of laudanum and a drachm of spirits of chloroform may be given, or, if the
colic is very intense, a hypodermic of a quarter of a grain of morphia. It is
not well to check the diarrhoea unless it is profuse, as it usually stops spon-
taneously within forty-eight hours. If persistent, the aromatic chalk powder
or large doses of bismuth (30 to 40 grains) may be given. A small enema
of starch (2 ounces) with 20 drops of laudanum, every six hours, is a most
valuable remedy.
(&) Chronic diarrhoea, including chronic catarrh and ulcerative enteritis.
It is important, in the first place, to ascertain, if possible, the cause and
whether ulceration is present or not. So much in treatment depends upon
the careful examination of the stools — as to the amount of mucus, the pres-
ence of pus, the occurrence of parasites, and, above all, the state of digestion
of the food — that the practitioner should pay special attention to them. Many
cases simply require rest in bed and a restricted diet. Chronic diarrhoea of
many months' or even of several years' duration may be sometimes cured by
strict confinement to bed and* a diet of boiled milk and albumen water.
In that form in which immediately after eating there is a tendency to
loose evacuations it is usually found that some one article of diet is at fault.
The patient should rest for an hour or more after meals. Sometimes this alone
is sufficient to prevent the occurrence of the diarrhoea. In those forms which
depend upon abnormal conditions in the small intestine, either too rapid peris-
talsis or faulty fermentative processes, bismuth is indicated. It must be given
in large doses — from half a drachm to a drachm three times a day. The
smaller doses are of little use. Kaphthalin preparations here do much good,
given in doses of from 10 to 15 grains (in capsule) four or five times a day.
Larger doses may be needed. Salol and the salicylate of bismuth may be tried.
An extremely obstinate and intractable form is the diarrhoea of hysterical
women. A systematic rest cure will be found most advantageous, and if a
milk diet is not well borne the patient may be fed exclusively on egg albumen.
The condition seems to be associated in some cases with increased peristalsis,
and in such the bromides may do good, or preparations of opium may be neces-
sary. There are instances which prove most obstinate and resist all forms of
treatment, and the patient may be greatly reduced. A change of air and
surroundings may do more than medicines.
504 .DISEASES OF THE DIGESTIVE SYSTEM.
In a large group of the chronic diarrhoeas the mischief is seated in the
colon and is due to ulceration. Medicines hy the mouth are here of little value.
The stools should be carefully watched and a diet arranged which shall leave
the smallest possible residue. Boiled or peptonized milk may be given, but the
stools should be examined to see whether there is an excess of food or of curds.
Meat is, as a rule, badly borne in these cases. The diarrhoea is best treated
by enemata. The starch and laudanum should be tried, but when ulceration
is present it is better to use astringent injections. From 2 to 4 pints of warm
water, containing from half a drachm to a drachm of nitrate of silver, may
be used. In the chronic diarrhoea which follows dysentery this is particularly
advantageous. In giving large injections the patient should be in the dorsal
position, with the hips elevated, and it is best to allow the injection to flow
in gradually from a siphon bag. In this way the entire colon can be irrigated
and the patient can retain the injection for som« time. The silver injections
may be very painful, but they are invaluable in all forms of ulcerative colitis.
Acetate of lead, boracic acid, sulphate of copper, sulphate of zinc, and sali-
cylic acid may be used in l-per-cent solutions.
In the intense forms of choleraic diarrhoea in adults associated with con-
stant vomiting and frequent watery discharges the patient should be given at
once a h3-podermic of a quarter of a grain of morphia, which should be re-
peated in an hour if the pains return or the purging persists. This gives
prompt relief, and is often the only medicine needed in the attack. The
patient should be given stimulants, and, when the vomiting is allayed by
suitable remedies, small quantities of milk and lime water.
II. DIARRHGE3AL DISEASES IN CHILDREN.
Children are particularly susceptible to disorders of the alimentary tract.
Although several forms are recognized, they so often merge the one into the
other that a sharp differentiation is impossible.
General Etiology. — Certain factors predispose to diarrhoea. Age. — The
largest number of cases occur just after the nursing period; the highest mor-
tality is in the second half of the first year, when this period falls in the hot
weather ; hence the dread of the " second summer."
Diet. — Diarrhoea is most frequent in artificially fed babies. Of nineteen
hundred and forty-three fatal cases collected by Holt, only 3 per cent were
breast-fed. The recent agitation for 23ure milk in the large cities has de-
creased materially the number of diarrhoea cases among bottle-fed infants.
Among the poor the bowel complaint comes with artificial feeding, and
is due either to milk ill Suited in quantity or poor in quality or to indigestible
articles of diet. Very many of the fatal cases have been fed upon condensed
milk.
Temperature. — The relation of the atmospheric temperature to the preva-
lence of the disease in children has long been recognized. The mortality curve
begins to rise in May, increases in June, reaching the maximum in July, and
gradually sinks through August and September. The maximum corresponds
closely with the highest mean temperature, yet we can not regard the heat
itself as the direct agent, but only as one of several factors. Thus the mean
temperature of June is only four or five degrees lower than that of July, and
DISEASES OF THE INTESTINES. 505
yet the mortality is not more than one-third. Seibert, who has carefully ana-
lyzed the mortality and the temperature month by month in New York for
ten years, fails to find a constant relation between the degrees of heat and the
number of cases of diarrhoea. Neither barometric pressure nor humidity
appears to have any influence.
Bacteeiology. — The discovery by Duvall and Bassett, working at the
Thomas Wilson Sanitarium, in the dejecta of children suffering from summer
diarrhoea, of a bacillus apparently identical with the organism shown by Shiga
to be the cause of epidemic dysentery in Japan, has awakened renewed interest
in the relation of bacteria to these disorders in children.
The Eockefeller Institute research (1903) showed that this organism was
present in a large number of cases of so-called " summer diarrhoea." No in-
stances of cholera infantum were studied. The laboratory studies of Martini
and Lentz, Flexner, Hiss, Parke, and others, indicate that there is a group
of closely allied forms of bacilli differing slightly from the original Shiga
bacillus in their action on certain sugars and in agglutinating properties.
The type of organisms most frequently associated with the diarrhoeas of
children belongs to the so-called " acid type," and, unlike the Shiga cultures,
ferments mannite with acid production.
The causal comiection of this group of bacteria with all the diarrhoeal dis-
eases of children has not been proven. In the hands of some workers they
have been found in the faces of a large proportion of all cases examined, and
also less frequently in the sporadic diarrhoeas occurring throughout the year.
These organisms are often found in comparatively small numbers, and are
more easily isolated from mucus or blood-stained stools. They occur in the
acute primary intestinal infection in children, in subacute infection without
previous symptoms coincident with or following other acute diseases such as
measles, pneumonia, etc., and in the terminal intestinal infection following
malnutrition or marasmus. They have been found in breast-fed infants as
well as bottle-babies.
The mode of entrance of the organism has not been determined. Simul-
taneous outbreaks of many cases in remote parts of a community where there
can be no common milk supply, and occurrence of the disease in breast- and
condensed-milk-fed babies, indicates that cow's milk is not the only conveyer
of the infection, and points to some common cause, possibly to the water, as
a means of contamination, although dysentery bacilli have not yet been iso-
lated from city water.
The importance of other organisms must not be overlooked. The observa-
tions of Escherich showed the remarkable simplicity of bacterial flora in the
intestines of healthy milk-fed children, hacterium lactis cerogenes being present
in the upper portion of the bowel and hacterium coli commune in the lower
bowel, each almost in pure culture.
When diarrhoea is set up the number and varieties of bacteria are greatly
increased, although heretofore no forms had been found to bear a constant or
specific relationship to the diarrhoeal faeces.
Certain diarrhoeas in children are apparently induced by the lactic acid
organisms in milk, others by colon or proteus hacilli, and others, again, by the
pyogenic cocci and other forms; all these bacteria may be associated with the
dysentery bacilli.
U
506 DISEASES OF THE DIGESTIVE SYSTEM.
There is considerable evidence to support the view that the destructive
lesions of the intestines ma}^ be produced by the streptococcus pyogenes after
an initial infection with a member of the dysenter}^ group.
Morbid Anatomy. — In mild cases there may be only a slight catarrhal
swelling of the mucosa of both small and large bowel, with enlargement of
the lymph follicles. The mucous membrane may be irregularh^ congested;
often this is most marked at the summit of the folds. The submucosa is usu-
ally infiltrated with serum and small round cells. In more severe cases ulcera-
tion may take place. The loss of substance begins, usually, in the mucosa,
over swollen lymph follicles. About the ulcer there is a more or less distinctly
marked inflammatory zone. The destruction of the tissue is limited to the
region of the follicles and becomes progressive by the union of several adjoin-
ing ulcers. This process is usually confined to the lower bowel, and may be
so extensive as to leave onh' ribbons of intact mucosa. The ulcers never per-
forate.
Rarel}^ there is a croupous or pseudo-membranous enteritis affecting the
lower ilium, colon, and rectum. The constant features are the increased secre-
tion of mucus and the lymphoid hyperplasia. The mesenteric glands are en-
larged. The changes in the other organs are neither numerous nor charac-
teristic.
Broncho-pneumonia occurs in many cases. The liver is often fatty, the
spleen may be swollen. Brain lesions are rare; the membranes and substance
are often ansemic, but meningitis or thrombosis is very uncommon.
Clixical Forms.
Acnte Intestinal Indigestion. — This form occurs in children of all ages,
and is associated with improper food. The symptoms often begin abruptly
with nausea and vomiting, or, especially in stronger children, several hours
or a day or two after the disturbing diet. The local s}Tnptoms are colicky
pains, moderate tvnnpanites, and diarrhoea. The stools are four to ten in
twenty-four hours; at first faecal, then fluid, with more or less mucus and
particles from undigested material. There is no blood. The usual intestinal
bacteria are found. Occasionally, when there is mucus, dj^sentery bacilli are
present. There is always fever. It is rarely very high, and never continues.
The pulse may be rapid and the prostration marked in very 3^oung or weak
children. These symptoms usually subside shortly after the emptying of the
bowel.
In weakened infants, or when the treatment has been delayed or the diet
remains unchanged, this disturbance may lead to more serious conditions.
Attacks of intestinal indigestion tend to recur.
Acute Dyspepsia, or Fermentative Diarrhoea. — This form is characterized
by more severe constitutional sjnnptoms. It may begin after an intestinal
indigestion of several days in which the stools are fluid and offensive, and
contain undigested food and curds. In other cases the disease sets in
abruptly with vomiting, griping pains, and fever, which may rapidly reach
104°-105° F.
I^ervous symptoms are usually prominent. The child is irritable and
sleeps poorly. Convulsions may usher in the acute sjonptoms or occur later.
DISEASES OF THE INTESTINES. 507
An increasing drowsiness, ending in coma, has been noted in many cases. The
stools, which vary from four to twenty in twenty-four hours, soon lose their
fgecal character and become fluid. Later they consist largely of green or
translucent mucus. An occasional fleck of blood is noticed in the mucus, but
this is never present in large amounts.
Microscopically, besides the food residue and mucous strands are a mod-
erate number of leucocytes and red blood-corpuscles. Epithelial cells are
found with numerous bacteria.
The acute symptoms generally pass away in a few days with judicious
treatment. Eelapses are frequent, following any indiscretion. The attack
may be the beginning of severe ileo-colitis.
These gastro-intestinal intoxications are largely confined to the summer
months and form an important group of the summer diarrhoeas of children.
Cholera Infantum. — This term should be reserved for the fulminating
form of gastro-intestinal intoxication. The typical cases are rare and form
only a very small proportion of the diarrhoeal diseases of infants. The disease
sets in with vomiting, which is incessant and is excited by an attempt to take
food or drink. The stools are profuse and frequent; at first fsecal in charac-
ter, brown or yellow in color, and finally thin, serous, and watery. The stools
first passed are very offensive ; subsequently they are odorless. The thin, serous
stools are alkaline. There is fever, but the axillary temperature may register
three or more degrees below that of the rectum. From the outset there is
marked prostration; the eyes are sunken, the features pinched, the fontanelles
depressed, and the skin has a peculiar ashy pallor. At first restless and ex-
cited, the child subsequently becomes heavy, dull, and listless. The tongue
is coated at the onset, but subsequently becomes red and dry. As in all
choleraic conditions, the thirst is insatiable; the pulse is rapid and feeble, and
toward the end becomes irregular and imperceptible. Death may occur within
twenty-four hours, with symptoms of collapse and great elevation of the in-
ternal temperature. Before the end the diarrhoea and vomiting may cease.
In other instances the intense symptoms subside, but the child remains torpid
and semi-comatose, with fingers clutched, and there may be convulsions. The
head may be retracted and the respirations interrupted, irregular, and of the
Cheyne- Stokes type. The child may remain in this condition for some days
without any signs of improvement. It was to this group of symptoms in
infantile diarrhoea that Marshall Hall gave the term " hydrencephaloid," or
spurious hydrocephalus. As a rule, no changes in the brain or other organs
are found. The condition of sclerema is described as a sequel of cholera
infantum. The skin and subcutaneous tissue becomes hard and firm, and the
appearance has been compared to that of a half -frozen cadaver.
No constant organism has been found in these cases. Baginsky considers
the disease the result of the action on the system of the poisonous products
of decomposition encouraged by the various bacteria present — a Fdulniss dis-
ease. The clinical picture is that produced by an acute bacterial infection,
as in Asiatic cholera.
Diagnosis. — The diagnosis is readily made. There is no other intestinal
affection in children for which it can be mistaken. The constant vomiting,
the frequent watery discharges, the collapse symptoms, and the elevated tem-
perature make an unmistakable clinical picture. The outlook in the majority
508 DISEASES OF THE DIGESTIVE SYSTEM.
of cases is bad, particularly in children artificially fed. Hyperpyrexia, ex-
treme collapse, and incessant vomiting are the most serious symptoms.
Ileo-colitis {Entero-colitis, Inflammatory Diarrhcea). — In this form there
is evidence of an inflammatory alteration of the intestinal wall, usually of the
lower ileum and large intestine. Several sub-varieties are recognized according
to the nature and site of the lesions. Many of the cases are grafted on the
simple forms above described. The mucous discharges continue, mingled with
food residue and often streaked with blood. Pus cells are numerous under
the microscope. The temperature remains elevated or may be remittent.
After two or three weeks the symptoms gradually subside, the stools become
fewer in number, and the fscal character returns.
In other instances the severe involvement of the intestines seems evident
within a few hours of the onset, with abdominal pain, vomiting, and fever.
Blood and pus may be present in nearly every stool. Tenesmus is frequent
and prolapsus ani is not uncommon. In severe attacks the prostration is
marked, the tongue is dry, the mouth covered with sordes, and death may
ensue in a few days from profound sepsis, or, if the acute stage is survived,
the case may continue desperately ill for weeks, gradually recover, or die from
asthenia.
Haemorrhage of large amounts of blood is extremely rare. The appearance
of bright red stains on the napkin indicates, usually, ulceration of the lower
bowel or rectum. When the blood is dark brown the lesion is in the ileum or
near the valve. The extent of the ulceration can not be accurately determined
by the quantity of the blood passed.
Membranous-colitis is usually only to be distinguished by the discovery
of the membrane in the rectum through a speculum or in prolapsus, or by
the passage of a fragment of the membrane in the stools.
Inflammation of the colon often occurs in marantic infants. It may con-
sist of a catarrhal or follicular inflammation of the lower bowel without
destructive lesion, and is frequently a terminal infection.
Ileo-colitis may become chronic and persist for months. The signs of
active inflammation subside; there is little pain or fever, but more or less
mucus remains in the stools. The general condition of the child suffers.
There is a continuous loss in weight; the skin is dry and hangs in folds;
nervous symptoms are always present. There may be stiffness and contrac-
tion of the extremities, with opisthotonus. The progress of the disease is
irregular, marked by short periods of improvement. Death is often due to a
relapse, to asthenia, or to broncho-pneumonia. In many of these cases, both
acute and chronic, the dysentery bacilli have been found in association with
other organisms.
Prevention. — Unquestionably, most of the intestinal disorders of children
can be prevented. In many of our large cities the mortality from the summer
diarrhoeas has been greatly reduced by prophylactic measures.
The infant should have abundance of air-space in the home, with plenty
of sunlight and fresh air. In hot weather, it may be well for him to sleep
out of doors, day and night. His clothing must not be too heavy in midsum-
mer; often only a binder and thin dress. This clothing should be altered
with every change of the temperature. The greatest cleanliness should sur-
round the life of the baby, and the nursing-bottles and nipples are to be
DISEASES OF THE INTESTINES. 509
boiled each day and kept scrupulously clean. Breast-feeding is continued
whenever possible.
Diet. — With bottle-babies, in warm weather, the d'iet should be reduced
in strength — i. e., weaker milk mixtures used and more water given. In all
crowded communities the milk should be sterilized or pasteurized during the
summer months, and all the water given the baby, either with or between the
nourishment, boiled. It is better that a child should be in the country during
the hot weather, but when this is impossible the various parks in our large
cities afford much relief.
Treatment. — Hygienic Management. — Even after the illness has begun,
much can be done by hygienic measures to diminish the severity. Change of
air to seashore or mountain is often followed by a marked improvement in
the child's condition. The patient must not be too warmly clad. The tem-
perature may be lowered and nervous symptoms allayed by hydrotherapy.
Baths, warm and cool, are helpful. Colon irrigations serve the double purpose
of flushing the bowel and stimulating the nervous system. They should be
given cool when there is much fever.
Medicinal. — In all cases of diarrhoea there is more or less congestion of
the intestinal mucosa, hypersecretion of mucus, and increased peristalsis due in
part to the irritant action of improper food. In certain forms toxic symptoms
from the absorption of poisons from the intestinal tract are early noticed. In
other instances, inflammatory lesions in the wall of the bowel are present.
The keynote, then, of the treatment is promptness. IsTature's effort to remove
the disturbing cause should be assisted, not checked, and care must be taken
to introduce food that will afford the least pabulum for the disturbing bacteria.
Castor-oil and calomel are to be preferred as purgatives, especially for
ijifants. A drachm of the former repeated, if necessary, will usually sweep
the intestinal tract and relieve the irritation. Where there is much nausea
or intestinal fermentation, calomel is indicated. It may be given in divided
doses at short intervals until one or two grains have been taken, or until the
characteristic green stools appear. Very early in the attack, if nausea is a
marked symptom, nothing relieves so quickly as gastric lavage with warm
water, or a weak soda solution when there is much acidity. In older children,
a large draught of boiled water may be substituted. In many cases irrigation
of the lower bowel with large quantities of salt solution flushes the colon,
removing the irritating material, and diminishes the absorption of toxins. It
also reduces the temperature and allays nervous symptoms. The irrigating
fluid should be cool when there is much fever. The infant is placed in the
dorsal position or turned a little to the left, with hips elevated, and the fluid
from a fountain syringe, about three feet above the patient, is allowed to flow
into the rectum through a large soft rubber catheter. Usually about a pint
can be retained before expulsion. If desired, the catheter can be gently
pushed into the bowel as it becomes distended with fluid. Two or three quarts
should be used at one irrigation, which may be repeated several times in
twenty- four hours if it is beneficial.
Where there is ulceration of the lower bowel, various astringents, such as
alum, witch hazel (one or two teaspoonfuls to one quart), silver nitrate,
1-4,000, or a weak solution of permanganate of potassium, may be used as
the irrigating fluid.
510 DISEASES OF THE DIGESTIVE SYSTEM.
When there is much loss of fluid from the body or when toxic s}Tnptoms
are marked, infusion of normal salt solution under the skin may be tried.
One to three hundred cc. of the solution can be readily introduced. This
procedure is not so permanentl}^ helpfiil as it was thought to be some years
ago. There is rarely any necessity to transfuse.
Of the many drugs vaunted as intestinal astringents and antiseptics, bis-
muth, either as subgallate or subnitrate, has proven most serviceable. It
should not be given until the disturbing material has been removed and the
temperature is falling; then it should be administered in large doses, 5 to 10
grains every hour, until there is discoloration of the stools. In some cases
this may be hastened by lac sulphur in grain doses. Opium should be very
sparingly used, and then onl}' for a specific purpose, to cheek excessive peri-
stalsis, violent colic, or very numerous passages. It may be given to an in-
fant as Dover's powders, ^1 gr. ; or paregoric, 5-10 minims every four
hours; or morphia, h}^odermically, -^^--^ gr., when prompt action is de-
sired. Occasionally it is well to combine it with atropia, joW ~ Jiro g^.
The bowels should not be locked when the stools are foul or the temperature
is high.
In all cases where there is prostration, stimulants are indicated. Alcohol,
such as brandy or whisky, ^ to 1 oz. in twenty-four hours in frequent doses,
diluted six to ten times with water, or, where there is much nausea, cham-
pagne with cracked ice, is most helpful. Strychnine, twt-i-wo gr., or digi-
talin in similar doses, may be indicated. Musk and camphor are also excellent
stimulants.
Serum Therapy. — Thus far the results of serum therapy have been dis-
appointing. Of 83 cases collected during the summer of 1903 by the Eocke-
feller Institute, there were no cures which could be certainly ascribed to the
serum, nor was the mortality, as compared with previous years, appreciably
lowered by serum prepared from either the so-called acid or alkaline type or
organism. In nearly all instances, however, in which the serum was given,
several days had elapsed after the onset of the illness. It was only in the
very early cases that any improvement at all was noticed. It may be that
an earlier trial will be followed by better results.
Certainly the marked reduction in the mortality in adult dysentery in
Japan, reported by Shiga, should encourage the further trial of this treatment
in the epidemic-diarrhoea, as no ill effects whatever have been ascribed to its
use. It is given in 10-40 cc. doses, h}-podermically.
Diet. — The dietetic management is of the utmost importance. In acute
cases with fever, the milk, whether breast or cow's milk, and all its modifica-
tions, must be stopped at once. It is best to give the infant nothing but
water for several hours, it may be for two or three days, or until the acute
symptoms subside ; a cereal water may then be substituted, preferably dextrin-
ized, to which may be added egg albumen, broth, or beef juice. Preparations
of broth and beef juice, and occasionally a weak tea, may be given. The time
at which it is safe to return to a milk diet varies with each case, and no defi-
nite rules can be laid down. It is usually better to defer milk until the tem-
perature is nearly normal.
If the stools are offensive from proteid decomposition, a diet consisting
largely of carbohydrates — i. e., barley water — is indicated ; whereas proteid
DISEASES OF THE INTESTINES. 511
diet, such as beef juice and egg albumen, is more helpful when the stools are
strongly acid.
Experience has shown that the ingredient in the milk that is not well borne
is the fat; hence skimmed milk, diluted or partially digested, can often be
safely given before diluted whole milk. Whey is often helpful.
In Germany, buttermilk has been widely used in convalescence from intes-
tinal disturbances.
The various proprietary foods, or condensed milk mixed with water, al-
though not to be given over long periods, may be found serviceable in the
gradual return of the child to a normal diet.
In children from three to seven years of age these acute derangements are
rarely serious, and usually respond promptly after purgation and restricted
diet, consisting largely of boiled milk.
It must be borne in mind that injudicious treatment, either in diet or
medication, may interrupt what otherwise would be a prompt recovery and
bring on the most serious intestinal lesions. The chronic cases, both in infants
and older children, especially those with ileo-colitis and ulceration in the gut,
present unusual difficulties. Each case must be studied by itself. Food which
is digested in the upper portion of the intestinal tract is preferable. Milk,
properly modified with cereal water or predigested, if intelligently prescribed,
offers the best chance of success. The so-called percentage system of milk
modification, which enables the physician to alter at will the proportion of
fat or carbohydrate present in the milk mixture, is of great service in feeding
these long-standing cases.
Care must be taken not to over-feed, although occasionally when there is
persistent anorexia, gavage may be necessary. This is best accomplished
through a nasal tube. Some infants will retain food given through a catheter
when they will vomit the same mixture taken from a bottle. Beef juice or
one of the beef-peptone preparations is frequently useful. They should
always be given with considerable fluid. In a large majority of instances
ulceration is confined to the large intestine, and can be reached by local
treatment.
Irrigations which flush the injured surface are of service. They should
be discontinued if much exhaustion follows; this is rarely the case.
No very definite results have followed the various astringent preparations
recommended. Probably warm salt or weak soda solutions are as useful. Sil-
ver nitrate is stimulating and healing where the ulcerations are in the rectum.
In great local irritation and tenesmus, enemata (2 oz.) of flaxseed or starch,
with 2 to 5 drops of laudanum, are soothing and beneficial.
Treatment of Cholera Infantum. — In cholera infantum serious symptoms
may occur with great rapidity, and here the incessant vomiting and frequent
purging render the administration of remedies extremely difficult. Irrigation
of the stomach and large bowel is of great service, and when the fever is high
ice-water injections may be used, or a graduated bath. As in the acute chol-
eraic diarrhoea of adults, morphia hypodermically is the remedy which gives
greatest relief, and in the conditions of extreme vomiting and purging, with
restlessness and collapse symptoms, this drug alone commands the situation.
A child of one year may be given from t^o" to ^\ of a grain, to be repeated
in an hour, and again if not better.
512 DISEASES OF THE DIGESTIVE SYSTEM.
In all eases of diarrhoea convalescence requires very careful management.
An infant which has suffered from a severe attack should be especially watched
throughout the remainder of the hot weather. During this time it is rarely
safe to return to a full diet.
ni. APPENDICITIS.
Inflammation of the vermiform appendix is the most important of acute
intestinal disorders. Formerly the " iliac phlegmon " was thought to be due
to disease of the caecum — ^typhlitis — or of the peritoneum covering it — ^peri-
typhlitis; but we now know that with rare exceptions the caecum itself is not
affected, and even the condition formerly described as stercoral typhlitis is in
reality appendicitis. The history is very fully given in the monograph of
Kelly and Hurdon. Melier and Dupuytren in France, Addison, Bright, and
Hodgkin in England, recognized the importance of the appendix, but to'
American physicians and surgeons is largely due the modern appreciation of
appendicitis as a common and serious disease. The contribution of Fitz in.
1886 served to put the whole question on a rational basis.
Etiology. — Incidence of the Disease. — In New York, in 1903, there were
439 deaths, 139 per million; in England and Wales, in 1903, there were 1,729'
deaths (Tatham), and in Chicago, 140 deaths per million inhabitants. Among:
8,043 deaths in the Boston City Hospital in the decade ending 1901, 179
(2.2 per cent) were due to appendicitis, which may be taken as the average
percentage of death in America. This is considerably higher than the Ger-
man figures, which are 0.3 per cent in Vienna (ISTothnagel) and 0.5 per cent
in Munich (Einhorn).
The exciting causes of appendicitis are not always evident. An infection
is in all probability the essential factor. The lumen of the appendix forms;
a sort of test-tube, in which the faeces lodge and are with difficulty discharged,
so that the mucosa is liable to injury from retention of the secretions or from
the presence of inspissated fasces or occasionally foreign bodies. In some in-
stances the appendicitis is a local expression of a general infection. Some
have thought that the great increase in the prevalence of the disease is due
to influenza. By some the poison of rheumatic fever is believed to be a cause,
and just as it may excite tonsillitis, so it may cause inflammation of the lym-
phatic tissues of the appendix. It is remarkable, too, that there may be two
or three cases of appendicitis at the same time in one family. The acute catar-
rhal form may be associated with pneumonia or typhoid fever or any of the
acute infections. Direct injury, as in straining and heavy lifting, is an occa-
sional cause.
The bacteriology of the disease is most varied. The bacillus coli is present
in a large number of cases, and the pyogenic organisms, particularly the strep-
tococcus pyogenes and the proteus vulgaris.
Age. — Appendicitis is a disease of young persons. According to Fitz's
statistics, more than 50 per cent of the cases occur before the twentieth- year ;
according to Einhorn's, 60 per cent between the sixteenth and thirtieth years.
It has been met with as early as the seventh week, but it is rarely seen prior
to the third year.
Sex. — lit is about equally common in males and in females.
DISEASES OF THE INTESTINES. 513
Occupation. — Persons whose work necessitates the lifting of heavy weights
seem more prone to the disease. Trauma plays a very definite role, and in a
number of cases the symptoms have followed very closely a fall or a blow.
Indiscretions in diet are very prone to bring on an attack, particularly in
the recurring form of the disease, in which pain in the appendix region not
infrequently follows the eating of indigestible articles of food.
Varieties. — It is not easy to classify the forms of inflammation of the
appendix. The following are the most important:
Acute catarrhal, in which the mucosa only is involved in a mild infec-
tion, causing swelling, a little oedema, and increased secretion, usually of a
muco-pus. This form may give rise to no symptoms whatever, or there may
be occasional colicky pains.
Acute diffuse appendicitis is more common. There is inflammation
of the mucosa and thickening of the entire organ, which becomes rigid and
tense, and the peritoneal surface hypersemic. There may be erosions of the
mucosa, or even small ulcers.
Purulent appendicitis is a more advanced stage of the former. Very
often the lumen of the tube is obstructed and pus is retained, forming a defi-
nite sac, varying greatly in size.
Gangrenous appendicitis is characterized by necrosis, local or general.
Most frequently the tip is involved, but a large portion of the organ may be-
come sphacelated, or in rare instances the entire appendix may slough off from
the cfficum.
In the acute diffuse, the purulent, or the gangrenous forms perforation
may take place in one or in several spots. It leads to either a wide-spread
peritonitis or a localized peritonitis with abscess formation, or very frequently,
if operation is not performed, to extensive abscess in the csecal region — sup-
purative peri-appendicitis.
Chronic appendicitis may follow the acute form, or the process may be
slow and gradual from the start. The organ is firm, slightly enlarged, the
coats thickened, and the mucosa thick and hypersmic. The lumen may be
narrowed. In some instances there are foreign bodies or concretions, and
there may be areas of erosion of the mucous membrane or partial obliteration
of the lumen.
Obliterative appendicitis is perhaps the most common form, as it seems
to be a gradual involution process in many individuals. The tube is thick-
ened, the peritoneal surface smooth; the distal portion of the lumen may be
entirely obliterated, and gradually the whole organ becomes sclerotic and
shrunken.
Faecal Concretions. — The lumen of the appendix may contain a mould of
faeces, which can readily be squeezed out. Even while soft the contents of the
tube may be moulded in two or three sections with rounded ends. Concretions
— enteroliths, coproliths — are also common. Of 700 cases of foreign bodies
there were 45 per cent of iseeal concretions (J. F. Mitchell). The enteroliths
often resemble in shape date-stones. The importance of these concretions is
shown by the great frequency with which they are found in all acute inflam-
mations of the appendix.
Foreign Bodies. — Of 1,400 cases of appendicitis collected by J. F. Mitchell
these were present in 7 per cent; in 28 cases pins were found. It is well to
514 DISEASES OF THE DIGESTIVE SYSTEM.
bear in mind that some of the concretions bear a very striking resemblance
to cherry and date stones.
Remote Effects. — The remote effects of perforative appendicitis are inter-
esting. Hemorrhage may occur. In one of mj' cases the appendix was ad-
herent to the promontory of the sacrum, and the abscess cavity had perfo-
rated in two places into the ileum. Death resulted from profuse hemorrhage.
Cases are on record in which the internal iliac artery or the deep circum-
flex iliac artery has been opened. Suppurative pyleiDhlebitis may result from
inflammation of the mesenteric veins near the perforated appendix. The
appendix may perforate in a hernial sac. Many instances of this have been
recorded.
After operation, thrombosis of the iliac or femoral veins is not uncommon,
and sudden death from pulmonary embolism has followed. - The leg may be
permanently enlarged. Hernia may occur in the wound. Strangulation of
the bowel is an occasional sequence. Eecurrence of the s^miptoms after opera-
tion has been noted, due in some cases to incomplete removal.
Symptoms. — In a large proportion of all cases of acute appendicitis the
following symptoms are present : ( 1 ) Sudden pain in the abdomen, usually
referred to the right iliac fossa; (2) fever, often of moderate grade; (3)
gastro-intestinal disturbance — nausea, vomiting, and frequently consti]3ation ;
(4) tenderness or pain on pressure in the appendix region.
Paix. — A sudden, violent pain in the abdomen is, according to Fitz, the
most constant, first, decided symptom of perforating inflammation of the ap-
pendix, and occurred in 84 per cent of the cases analyzed b}^ him. In fully
half of the cases it is localized in the right iliac fossa, but it may be central,
diffuse, but usually in the right half of the abdomen. Even in the cases in
which the pain is at flrst not in the appendix region, it is usually felt here
within thirty-six or forty-eight hours. It may extend toward the perinasum
or testicle. It is sometimes very sharp and colic-like, and cases have been
mistaken for nephritic or for biliary colic. Some patients speak of it as a
sharp, intense pain — serous-membrane pain ; others as a dull ache — connective-
tissue pain. While a very valuable symptom, pain is at the same time one
of the most misleading. Some of the forms of recurring pain in the appendix
region Talamon has called appendicular colic. The condition is believed to
be due to partial occlusion of the lumen, leading to violent and irregular
peristaltic action of the circular and longitudinal muscles in the expulsion
of the mucus.
Fever. — Fever is always present in the early stage, even in the mildest
forms, and is a most important feature. J. B. Murphy states that he would
not operate on a case in which he was confident that no fever had been present
in the first thirty-six hours of the disease. An initial chill is very rare. The
fever may be moderate, from 100° to 102°; sometimes in children at the very
outset the thermometer may register above 103.5.° The thermometer is one
of the most trustworthy guides in the diagnosis of acute appendicitis. Ap-
pendicular colic of great severity- may occur without fever. When a localized
abscess has formed, and in some very virulent cases of general peritonitis, the
temperature may be normal, but at this stage there are other symptoms which
indicate the gravity of the situation. The pulse is quickened in proportion
to the fever.
DISEASES OF THE INTESTINES. 515
Gastro-intestinal Disturbance.— ^The tongue is usually furred and
moist, seldom dry. Nausea and vomiting are symptoms which may be absent,
but which are commonly present in the acute perforative cases. The vomiting
rarely persists beyond the second day in favorable cases. Constipation is the
rule, but the attack may set in with diarrhoea, particularly in children.
Local Signs. — Inspection of the abdomen is at first negative ; there is
no distention, and the iliac fossae look alike. On palpation there are usually
from ftie outset two important signs — namely, great tension of the right rectus
muscle, and tenderness or actual pain on deep pressure. The muscular rigidity
may be so great that a satisfactory examination can not be made without an
aneesthetic. McBurney has called attention to the value of a localized point
of tenderness on deep pressure, which is situated at the intersection of a line
drawn from the navel to the anterior superior spine of ' the ilium, with a
second, vertically placed, corresponding to the outer edge of the right rectus
muscle. Firm, deep, continuous pressure with one finger at this spot causes
pain, often of the most exquisite character. In addition to the tenderness,
rigidity, and actual pain on deep pressure, there is to be felt, in a majority
of the cases, an induration or swelling. In some cases this is a boggy, ill-
defined mass in the situation of the caecum; more commonly the swelling is
circumscribed and definite, situated in the iliac fossa, two or three fingers'
breadth above Poupart's ligament. Some have been able to feel and roll be-
neath the fingers the thickened appendix. The later the case comes under
observation the greater the probability of the existence of a well-marked tumor
mass. It is not to be forgotten that there may be neither tumor mass nor
induration to be felt in some of the most intensely virulent cases of perfora-
tive appendicitis.
In addition may be mentioned great irritability of the bladder, which I
have known to lead to the diagnosis of cystitis. It may be a very early symp-
tom. The urine is scanty and often contains albumin and indican. Peptonu-
ria is of no moment. The attitude is somewhat suggestive, the decubitus is
dorsal, and the right leg is semi-flexed. Examination per rectum in the early
stages rarely gives any information of value, unless the appendix lies well
over the brim of the pelvis, or unless there is a large abscess cavity. Severe
cases usually show a leucocytosis of 15,000 to 24,000.
Albuminuria is common. Sometimes there is an acute nephritis, and Dieu-
lafoy has described an acute toxic form. He thinks that the kidneys are not
infrequently damaged in the disease.
There are three possibilities in any case of appendicitis: (1) Gradual re-
covery, (3) the formation of a local abscess, and (3) general peritonitis.
Recoveet is the rule. Out of 264 cases at St. Thomas's Hospital with
the above-mentioned clinical characters, 190 recovered. There are surgeons
who claim that the getting well in these cases does not mean much; that the
patients have recurrences and are constantly liable to the graver accidents of
the disease. This, I feel sure, is an unduly dark picture.
In a case which is proceeding to recovery the pain lessens at the end of
the second or third day, the temperature falls, the tongue becomes cleaner,
the vomiting ceases, the local tenderness is less marked, and the bowels are
moved. By the end of a week the acute symptoms have subsided. An indura-
tion or an actual small tumor mass from the size of a walnut to that of an
516 DISEASES OF THE DIGESTIVE SYSTEM.
egg may persist — a condition which leaves the patients very liable to a recur-
rence. So liable is the attack to recur that a special variety of relapsing
appendicitis is described.
Local Abscess Formation. — As a result of ulceration and perforation,
sometimes following the necrosis, rarely as a sequence of the diffuse appendi-
citis, the patient has the train of symptoms above described; but at the end
of the first week the local features persist or become aggravated. The course
of the disease may be indeed so acute that by the end of the fourth or fifth
day there is an extensive area of induration in the right iliac fossa, with great
tenderness, and operations have shown that even at this very early date an
abscess cavity may have formed. Though as a rule the fever becomes aggra-
vated with the onset of suppuration, this is not always the case. The two
most important elements in the diagnosis of abscess formation are the gradual
increase of the local tumor and the aggravation of the general s3Tiiptoms.
Nowadays, when operation is so frequent, we have opportunities of seeing the
abscess in various stages of development. Quite early the pus may lie between
the caecum and the coils of the ileum, with the general peritongeum shut off
by fibrin, or there is a sero-fibrinous exudate with a slight amount of pus
between the lower coils of the ileum. The abscess cavity may be small and
lie on the psoas muscle, or at the edge of the promontory of the sacrum, and
never reach a palpable size. The sac, when larger, may be roofed in by the
small bowel and present irregular processes and pockets leading in different
directions. In larger collections in the iliac fossa the roof is generally formed
by the abdominal wall. Some of the most important of the localized abscesses
are those which are situated entirely within the pelvis. The various directions
and positions into which the abscess may pass or perforate have already been
referred to under morbid anatomy, but it may be here mentioned again that,
left alone, it may discharge externally, or burrow in various directions, or be
emptied through the rectum, vagina, or bladder. Death may be caused by
septicaemia, by perforation into an artery or vein, or by pylephlebitis.
General Peritonitis. — This may be caused by direct perforation of the
appendix and general infection of the peritonaeum before any delimiting in-
flammation is excited. In a second group of cases there has been an attempt
at localizing the infective process, but it fails, and the general peritonasum
becomes involved. In a third group of cases a localized focus of suppuration
exists about an inflamed appendix, and from this perforation takes place.
Death in appendicitis is due usually to general peritonitis.
The gravity of appendix disease lies in the fact that from the very outset
the peritoncEum may he infected; the initial symptoms of pain, with nausea
and vomiting, fever, and local tenderness, present in all cases, may indicate
a wide-spread infection of this memhrane. The onset is usually sudden, the
pain diffuse, not always localized in the right iliac fossa, but it is not so much
the character as the greater intensity of the symptoms from the outset that
makes one suspicious of a general peritonitis. Abdominal distention,, diffuse
tenderness, and absence of abdominal movements are the most trustworthy
local signs, but they are not really so trustworthy as the general symptoms.
The initial nausea and vomiting persist, the pulse becomes more rapid, the
tongue is dry, the urine scanty. In very acute cases, by the end of twenty-four
hours the abdomen may be distended. By the third and fourth days the
DISEASES OF THE INTESTINES. 517
classical picture of a general peritonitis is well established — a distended and
motionless abdomen, a rapid pulse, a dry tongue, dorsal decubitus with the
knees drawn up, and an anxious, pinched, Hippocratic facies. Unfortunately,
the leucocyte count gives little aid.
Fever is an uncertain element. It is usually present at first, but if the
physician does not see the case until the third or fourth day he should not
be deceived by a temperature below 100.5°. The pulse is really a better indi-
cation than the temperature. One rarely has any doubt on the third or
fourth day whether or not peritonitis exists, but it must be acknowledged that
there are exceptions which trouble the judgment not a little. While on the
one hand, without suggestive symptoms, a laparotomy has disclosed an unex-
pected general peritonitis, on the other, with severe constitutional symptoms
and apparently characteristic local signs, the peritonaeum has been found
smooth.
Diagnosis. — Appendicitis is by far the most common inflammatory con-
dition, not only in the csecal region, but in the abdomen generally in persons
under thirty. The surgeons have taught us that, almost without exception,
sudden pain in the right iliac fossa, with fever and localized tenderness, with
or without tumor, means appendix disease. There are certain diseases of the
abdominal organs characterized by pain which are apt to be confounded with
appendicitis. Biliary colic, kidney colic, and the colicky pains at the men-
strual period in women have in some cases to be most carefully considered.
Diseases of the tubes and pelvic peritonitis may simulate appendicitis very
closely, but the history and the local examination under ether should in most
cases enable the practitioner to reach a diagnosis. I have seen several cases
supposed to be recurring appendicitis which proved to be tubo-ovarian disease.
The Dietl's crises in floating kidney have been mistaken for appendicitis.
Both intussusception and internal strangulation may present very similar
symptoms, and if the patient is only seen at the later stages, when there is
diffuse peritonitis and great tympany, the features may be almost identical.
Fsecal vomiting, which is common in obstruction, is never seen in appendicitis,
and in children the marked tenesmus and bloody stools are important signs
of intussusception. It is not often difficult to decide when the cases are seen
early and when the history is clear, but mistakes have been made by surgeons
of the first rank.
Acute hgemorrhagic pancreatitis may also produce symptoms very like
those of appendicitis with general peritonitis. The relation of typhoid fever
and appendicitis is interesting. The gastro-intestinal symptoms, particularly
the pain and the fever, may at the onset suggest appendicitis. Operations have
been comparatively frequent. In the second and third weeks of typhoid fever
perforation of the appendix may occur, and occasionally late in the convales-
cence perforation of an unhealed ulcer of the appendix.
There is a well-marked appendicular hypochondriasis. Through the per-
nicious influence of the daily press, appendicitis has become a sort of fad, and
the physician has often to deal with patients who have almost a fixed idea
that they have the disease. The worst cases of this class which I have seen
have been in members of our profession, and I know of at least one instance
in which a perfectly normal appendix was removed. The question really has
its ludicrous side. A well-known physician in a Western city having one night
518 DISEASES OF THE DIGESTIVE SYSTEM.
a bellyache, and feeling convinced that his appendix had perforated, sum-
moned a surgeon, who quickly removed the supposed offender !
Hysteria may of course simulate appendicitis very closely, and it may
require a very keen judgment to make a diagnosis.
Mucous colitis with enteralgia in nervous women is sometimes mistaken
for appendicitis. In two instances of the kind I have prevented proposed
operation, and I have heard of cases in which the appendix has been re-
moved.
Perinephritic and pericsecal abscess from perforation of ulcer, either sim-
ple or cancerous, and circumscribed peritonitis in this region from other
causes, can rarely be differentiated until an exploratory incision is made.
Chronic obliterative appendicitis can not always be differentiated from the
perforative form, and in intensity of pain, severity of symptoms, and, in rare
instances, even in the production of peritonitis, the two may be identical.
Briefly stated, localized pain in the right iliac fossa, with or without in-
duration or tumor, the existence of McBurney's tender point, fever, furred
tongue, vomiting, with constipation or diarrhoea, indicate appendicitis. The
occurrence of general peritonitis is suggested by increase and diffusion of the
abdominal pain, tympanites (as a rule), marked aggravation of the constitu-
tional symptoms, particularly elevation of fever and increased rapidity of the
pulse. Obliteration of hepatic dulness is rarely present, as the peritonaeum
in these cases does not often contain gas.
Prognosis. — While we can not overestimate the gravity of certain forms
of appendicitis, it is well to recognize that a large proportion of all cases
recover. It is the element of uncertainty in individual cases which has given
such an impetus to the surgical treatment of the disease. That an inflamed
appendix may heal perfectly, even after perforation, is shown by instances
(post mortem) of obliterated tubes flrmly imbedded in old scar tissue. In
1903, in England and Wales, appendicitis was assigned as a cause of 1,729
deaths, as compared with 1,244 and 1,485 in the preceding two years. The
mortality has been increasing of late years in spite of the earlier and better
surgery. Hawkins attributes this to an increased severity of the disease. The
mortality in the hands of surgeons ranges from 2 to 11 per cent, varying with
the variety and the stage of the disease at which operation is performed.
Treatment. — Gradually the profession has learned to recognize that appen-
dicitis is a surgical disease. In hospital practice the cases should be admitted
directly to the surgical wards. Many lives are lost by temporizing. The
general practitioner does well to remember — whether his leanings be toward
the conservative or the radical methods of treatment — that the surgeon is often
called too late, never too early.
There is no medicinal treatment of appendicitis. There are remedies
which will allay the pain, but there are none capable in any way of controlling
the course of the disease. Eest in bed, a light diet, measures directed to allay
the vomiting — upon these all are agreed. The practice of giving opium in
some form in appendicitis and peritonitis is almost universal with physicians.
Surgeons, on the other hand, almost unanimously condemn the practice, as
obscuring the clinical picture and tending to give a false sense of security ; and
since they control the situation, I think we should — deferring in this matter
to their judgment — not give opium, and trust to the persistent use of ice
DISEASES OF THE INTESTINES. 519
locally to relieve the pain. General opinion among the hest surgeons is, I
believe, opposed to the use of saline purges.
Operation is indicated in all cases of acute inflammatory trouble in the
csBcal region, whether tumor is present or not, when the general symptoms
are severe, and when at the end of forty-eight hours, or even earlier, the
features of the case point to a progressive lesion. The mortality from early
operation under these circumstances is very slight.
In recurring appendicitis, when the attacks are of such severity and fre-
quency as seriously to interrupt the patient's occupation, the mortality in the
hands of capable operators is very small.
IV. INTESTINAL OBSTRUCTION.
Intestinal obstruction may be caused by strangulation, intussusception,
twists and knots, strictures and tumors, and by abnormal contents.
Etiology and Pathology. — (a) Strangulation. — This is the most fre-
quent cause of acute obstruction, and occurred in 34 per cent of the 295 cases
analyzed by Fitz, and in 35 per cent of the 1,134 cases of Leichtenstern. Of
the 101 cases of strangulation in Fitz's table, which, has the special value of
having been carefully selected from the literature since 1880, the following
were the causes : Adhesions, 63 ; vitelline remains, 21 ; adherent appendix, 6 ;
mesenteric and omental slits, 6 ; peritoneal pouches and openings, 3 ; adherent
tube, 1 ; peduncular tumor, 1. The bands and adhesions result, in a majority
of cases, from former peritonitis. A number of instances have been reported
following operations upon the pelvic organs in women. The strangulation
may be recent and due to adhesion of the bowel to the abdominal wound or
a coil may be caught between the pedicle of a tumor and the pelvic wall. Such
cases are only too common. Late occlusion after recovery from the operation
is due to bands and adhesions.
The vitelline remains are represented by Meckel's diverticulum, which
forms a finger-like projection from the ileum, usually within eighteen inches
of the ileo-ca3cal valve. It is a remnant of the omphalo-mesenteric duct,
through which, in the early embryo, the intestine communicated with the
yolk-sac. The end, though commonly free, may be attached to the abdominal
wall near the navel, or to the mesentery, and a ring is thus formed through
which the gut may pass.
Seventy per cent of the cases of obstruction from strangulation occur in
males ; 40 per cent of all the cases occur between the ages of fifteen and thirty
years. In 90 per cent of the cases of obstruction from these causes the site
of the trouble is in the small bowel ; the position of the strangulated portion
was in the right iliac fossa in 67 per cent of the cases, and in the lower abdo-
men in 83 per cent.
(&) Intussusception. — In this condition one portion of the intestine slips
into an adjacent portion, forming an invagination or intussusception. The
two portions make a cylindrical tumor, which varies in length from a half-
inch to a foot or more. The condition is always a descending intussusception,
and as the process proceeds, the middle and inner layers increase at the ex-
pense of the outer layer. An intussusception consists of three layers of bowel :
the outermost, known as the intussuscipiens, or receiving layer ; a middle or
520 DISEASES OF THE DIGESTIVE SYSTEM.
returning layer ; and the innermost or entering layer. The student can obtain
a clear idea of the arrangement by making the end of a glove-finger pass into
the lower portion. The actual condition can be very clearly studied in the
post-mortem invaginations which are so common in the small bowel of chil-
dren. In the statistics of Fitz, 93 of 295 cases of acute intestinal obstruction
were due to this cause. Of these, 52 were in males and 27 in females. The
cases are most common in early life, S-i per cent under one year and 56 per
cent under the tenth year. Of 103 cases in children, nearly 50 per cent
occurred in the fourth, fifth, and sixth months (Wiggin). Xo definite causes
could be assigned in 42 of the cases; in the others diarrhoea or habitual con-
stipation had existed.
The site of the invagination varies. We may recognize (1) an ileo-ccBcal,
when the ileo-caecal valve descends into the colon. There are cases in which
this is so extensive that the valve has been felt per rectum. This form oc-
curred in 75 per cent of the cases; in 89 per cent of Wiggin's collected cases.
In the ileo-colic the lower part of the ileum passes through the ileo-csecal valve.
(2) The ileal^ in which the ileum is alone involved. (3) The colic^ in which
it is confined to the large intestine. And (4) coUco-rectal, in which the colon
and rectum are involved.
Irregular peristalsis is the essential cause of intussusception. jSTothnagel
found in the localized peristalsis caused by the faradic current that it was
not the descent of one portion into the other, but the drawing up of the
receiving layer by contraction of the longitudinal coat. Invagination may
follow any limited, sudden, and severe peristalsis.
In the post-mortem examination, in a case of death from intussusception,
the condition is very characteristic. Peritonitis may be present or an acute
injection of the serous membrane. When death occurs early, as it may do
from shock, there is little to be seen. The portion of bowel affected is large
and thick, and forms an elongated tumor with a curved outline. The parts
are swollen and congested, owing to the constriction of the mesentery between
the layers. The entire mass may be of a deep livid-red color. In very recent
processes there is only congestion, and perhaps a thin layer of lymph, and the
intussusception can be reduced, but when it has lasted for a few days, hmipb
is thrown out, the laj-ers are glued together, and the entering portion of the
gut can not be withdravm.
The anatomical condition accounts for the presence of the tumor, which
exists in two-thirds of all cases ; and the engorgement, which results from the
compression of the mesenteric vessels, explains the frequent occurrence of
blood in the discharges, which has so important a diagnostic value. If the
patient survives, necrosis and sloughing of the invaginated portion may occur,
and if union has taken place between the inner and outer layers, the calibre
of the gut may be restored and a cure in this way effected. Many cases of
the kind are on record. In the Museum of the Medical Faculty of the McGill
University are 17 inches of small intestine, which were passed by a lad
who had symptoms of internal strangulation, and who made a complete
recovery.
(c) Twists axd Kxots. — ^^-^olvnlus or twist occurred in 42 of the 295
cases (Fitz). Sixty-eight per cent were in males. It is most frequent be-
tween the ages of thirty and forty. In the great majority of all cases the^
DISEASES OF THE INTESTINES. 521
twist is axial and associated with an unusually long mesentery. In 50 per
cent of the cases it was in the sigmoid flexure. The next most common situa-
tion is about the caecum, which may be twisted upon its axis or bent upon
itself. As a rule, in volvulus the loop of bowel is simply twisted upon its long
axis, and the portions at the end of the loop cross each other and so cause the
strangulation. It occasionally happens that one portion of the bowel is twisted
about another.
(d) Strictures and Tumors. — These are very much less important causes
of acute obstruction, as may be judged by the fact that there are only 15 in-
stances out of the 295 cases, in 14 of which the obstruction occurred in the
large intestine ( Fitz ) . On the other hand, they are common causes of chronic
obstruction.
Lipoma may occur, growing from the submucosa, and cause intussuscep-
tion. In a number of cases the tumor has been passed per rectum. S. B. Ward
has collected 9 cases.
The obstruction may result from: (1) Congenital stricture. These are
exceedingly rare. Much more commonly the condition is that of complete
occlusion, either forming the imperforate anus or the congenital defect by
which the duodenum is not united to the pylorus. (3) Simple cicatricial
stenosis, which results from ulceration, tuberculous or syphilitic, more rarely
from dysentery, and most rarely of all from typhoid ulceration. (3) New
growths. The malignant strictures are due chiefly to cylindrical epithelioma,
which forms an annular tumor, most commonly met with in the large bowel,
about the sigmoid flexure, or the descending colon. Of benign growths, papil-
lomata, adenomata, lipomata, and fibromata occasionally induce obstruction.
(4) Compression and traction. Tumors of neighboring organs, particularly
of the pelvic viscera, may cause obstruction by adhesion and traction; more
rarely, a coil, such as the sigmoid flexure, filled with fgeces, compresses and
obstructs a neighboring coil. In the healing of tuberculous peritonitis the
contraction of the thick exudate may cause compression and narrowing of
the coils.
(e) Abnormal Contents. — Foreign bodies, such as fruit stones, coins,
pins, needles, or false teeth, are occasionally swallowed accidentally, or by
lunatics on purpose. Eound worms may become rolled into a tangled mass
and cause obstruction. In reality, however, the majority of foreign bodies,
such as coins, buttons, and pins, swallowed by children, cause no inconve-
nience whatever, but in a day or two are found in the stools. Occasionally such
a foreign body as a pin will pass through the oesophagus and will be found
lodged in some adjacent organ, as in the heart (Peabody), or a barley ear
may reach the liver (Dock).
Medicines, such as magnesia or bismuth, have been known to accumulate
in the bowels and produce obstruction, but in the great majority of the cases
the condition is caused by faeces, gall-stones, or enteroliths. Of 44 cases, in
23 the obstruction was by gall-stones, in 19 by faeces, and in 2 by enteroliths.
Obstruction by faeces may happen at any period of life. As mentioned when
speaking of dilatation of the colon, it may occur in young children and persist
for weeks. In faecal accumulation the large bowel may reach an enormous
size and the contents become very hard. The retained masses may be chan-
neled, and small quantities of faecal matter are passed until a mass too large
522 DISEASES OF THE DIGESTIVE SYSTEM.
enters the lumen and causes obstruction. There may be very few symptoms,
as the condition may be borne for weeks or even for months.
Obstruction by gall-stones is not very infrequent, as may be gathered from
the fact that 23 cases were reported in the literature in eight years. Eighteen
of these were in women and 5 in men. In six-sevenths of the cases it occurred
after the fiftieth year. The obstruction is usually in the ileo-caecal region,
but it may be in the duodenum. These large solitary gall-stones ulcerate
through the gall-bladder, usually into the small intestine, occasionally into the
colon. In the latter case they rarely cause obstruction. Courvoisier has col-
lected 131 cases in the literature.
Enteroliths may be formed of masses of hair, more commonly of the phos-
phates of lime and magnesia, with a nucleus formed of a foreign body or of
hardened ffeces. jSTearly every museum possesses specimens of this kind. They
are not so common in men as in ruminants, and, as indicated in Fitz's statis-
tics, are very rare causes of obstruction.
Symptoms. — (a) Acute Obstruction". — Constipation, pain in the abdo-
men, and vomiting are the three important symptoms. Pain sets in early
and may come on abruptly while the patient is walking or, more commonly,
during the performance of some action. It is at first colicky in character, but
subsequently it becomes continuous and very intense. Vomiting follows
quickly and is a constant and most distressing symptom. At first the contents
of the stomach are voided, and then greenish, bile-stained material, and soon,
in cases of acute and permanent obstruction, the material vomited is a brown-
ish-black liquid, with a distincth^ faecal odor. This sequence of gastric, bilious,
and, finally, stercoraceous vomiting is perhaps the most important diagnostic
feature of acute obstruction. The constipation may be absolute, without the
discharge of either fjeces or gas. A'^ery often the contents of the bowel below
the stricture are discharged. Distention of the abdomen usually occurs, and
when the large bowel is involved it is extreme. On the other hand, if the
obstruction is high up in the small intestine, there may be very slight tympany.
At first the abdomen is not painful, but subsequently it may become acutely
tender.
The constitutional symptoms from the outset are severe. The face is pallid
and anxious, and finally collapse sjnnptoms supervene. The eyes become
sunken, the features pinched, and the skin is covered with a cold, clammy
sweat. The pulse becomes rapid and feeble. There may be no fever; the
axillary temperature is often subnormal. The tongue is dry and parched and
the thirst is incessant. The urine is high-colored, scanty, and there may be
suppression, particularly when the obstruction is high up in the bowel. This
is probably due to the constant vomiting and the small amount of liquid which
is absorbed. The case terminates as a rule in from three to six days. In some
instances the patient dies from shock or sinks into coma. A leucocytosis of
75,000 or 80,000 per c. mm. may be present.
(h) Symptoms of Chronic Obstruction. — ^When due to fsecal impac-
tion, there is a history of long-standing constipation. There may have been
discharge of mucus, or in some instances the faecal masses have been chan-
neled, and so have allowed the contents of the upper portion of the bowel to
pass through. In elderly persons this is not infrequent; but examination,
either per rectum or externally, in the course of the colon, will reveal the
DISEASES OF THE INTESTINES. 523
presence of hard scybalous masses. There may be retention of fseces for weeks
without exciting serious symptoms. In other instances there are vomiting,
pain in the abdomen, gradual distention, and finally the ejecta become faecal.
The hardened masses may excite an intense colitis or even peritonitis.
In stricture, whether cicatricial or cancerous, the symptoms of obstruction
are very diverse. Constipation gradually comes on, is extremely variable, and
it may be months or even years before there is complete obstruction. There
are transient attacks, in which from some cause the fseces accumulate above
the stricture, the intestine becomes greatly distended, and in the swollen
abdomen the coils can be seen in active peristalsis. In such attacks there may
be vomiting, but it is very rarely of a faecal character. In the majority of
these cases the general health is seriously impaired; the patient gradually be-
comes angemic and emaciated, and finally, in an attack in which the obstruc-
tion is complete, death occurs with all the features of acute occlusion or the
case may be prolonged for ten or twelve days.
Diagnosis. — (a) The SiTUATioisr of the OBSTRUCTioisr. — Hernia must be
excluded, which is by no means always easy, as fatal obstruction may occur
from the involvement of a very limited portion of the gut in the external ring
or in the obturator foramen. Mistakes from both of these causes have come
under my observation; they were cases in which it was impossible to make a
diagnosis other than acute obstruction. Timely operation would have saved
both lives. A thorough rectal and, in women, a vaginal examination should
be made, which will give important information as to the condition of the
pelvic and rectal contents, particularly in cases of intussusception, in which
the descending bowel can sometimes be felt. In cases of obstruction high up
the empty coils sink into the pelvis and can there be detected. Eectal explora-
tion with the entire hand is of doubtful value. In the inspection of the abdo-
men there are important indications, as the special prominence in certain
regions, the occurrence of well-defined masses, and the presence of hypertro-
phied coils in active peristalsis. John Wyllie has called attention to the great
value in diagnosis of the " patterns of abdominal tumidity." * In obstruction
of the lower end of the large intestine not only may the horseshoe of the
colon stand out plainly, when the bowel is in rigid spasm, but even the pouches
of the gut may be seen. When the c^cum or lower end of the ileum is ob-
structed the tumidity is in the lower central region, and during spasm the
coils of the small bowel may stand out prominently, one above the other, either
obliquely or transversely placed — the so-called " ladder pattern." In obstruc-
tion of the duodenum or jejunum there may only be slight distention of the
upper part of the abdomen, associated usually with rapid collapse and anuria.
In the ileum and caecum the distention is more in the central portion of
the abdomen; the vomiting is distinctly faecal and occurs early. In obstruc-
tion of the colon, tympanites is much more extensive and general. Tenesmus
is more common, with the passage of mucus and blood. The course is not so
quick, the collapse does not supervene so rapidly, and the urinary secretion
is not so much reduced.
In obstruction from stricture or tumor the situation can in some cases be
accurately localized, but in others it is very uncertain. Digital examination
* Edinburgh Hospital Reports, vol. ii.
524 DISEASES OF THE DIGESTIVE SYSTEM.
of the rectum should first bo made. The rectal tube may then be passed, but
it is impossible to get be3'ond the sigmoid flexure. In the use of the rigid tube
there is danger of perforation of the bowel in the neighborhood of a stricture.
The quantity of fluid which can be passed into the large intestine should be
estimated. The capacity of the large bowel is about six quarts. Wiggin ad-
vises about a pint and a half from a height of three feet for an infant. To
thoroughly irrigate the bowel the patient should be cliloroformed and should
lie on the back or on the side — ^best on the back, with the Mps elevated. Treves
suggests that the CEecal region should be auscultated during the passage of the
fluid. For diagnostic purposes the rectum may be inflated, either by the bel-
lows or by the use of bicarbonate of soda and tartaric acid. In certain cases
these measures give important indications as to the situation of the obstruction
in the large bowel.
(&) jSTature of the Obstructiox. — This is often difficult, not infre-
quently impossible, to determine. Strangulation is not common in very early
life. In many instances there have been previous attacks of abdominal pain,
or there are etiological factors which give a clew, such as old peritonitis or
operation on the pelvic viscera. Xeither the onset nor the character of the
pain gives us any information. In rare instances nausea and vomiting may
be absent. The vomiting usually becomes faecal from the third to the fifth
day. A tumor is not common in strangulation, and was present in only one-
fifth of the cases. Fever is not of diagnostic value.
Intussusception is an affection of childhood, and is of all forms of internal
obstruction the one most readily diagnosed. The presence of tumor, bloody
stools, and tenesmus are the important factors. The tumor is usually sausage-
shaped and felt in the region of the transverse colon. It existed in 66 of 93
cases. It became evident the first day in more than one-third of the cases,
on the second day in more than one-fourth, and on the third day in more than
one-fifth. Blood ia the stools occurs in at least three-fifths of the cases, either
spontaneously or following the use of an enema. The blood may be mixed
with mucus. Tenesmus is present in one-third of the cases. Faecal vomiting
is not very common and was present in only 12 of the 93 instances. Abdom-
inal tympany is a s^Tnptom of slight importance, occurring in only one-third
of the cases.
Volvulus can rarely be diagnosed. The frequency with which it involves
the sigmoid fiexure is to be borne in mind. The passage of a flexible tube
or injecting fluids might in these cases give valuable indications.
In fcBcal obstruction the condition is usually clear, as the fgeces can be
felt per rectum and also in the distended colon. Faecal vomiting, tympany,
abdominal pain, nausea, and vomiting are late and are not so constant. In
obstruction by gall-stone a few of the cases gave a previous history of gall-
stone colic. Jaundice was present in only 2 of the 23 cases. Pain and vomit-
ing, as a rule, occur early and are severe, and f»cal vomiting is present in
two-thirds of the cases. A tumor is rarely evident.
(c) Diagnosis feom othee Co^^DITIO]s^s. — Acute enteritis with great re-
laxation of the intestinal coils, vomiting, and pain may be mistaken for
obstruction. In an autopsy on a case of this kind the small and large bowels
were intensely inflamed, relaxed, sodden, and enormously distended. The
symptoms were those of acute obstruction, but the intestine was free from
DISEASES OF THE INTESTINES. 525
duodenum to rectum. Of late years many instances have been reported in
which peritonitis following disease of the appendix has been mistaken for
acute obstruction. The intense vomiting, the general tympany and abdominal
tenderness, and in some instances the suddenness of the onset are very decep-
tive, and in two cases which have come under my notice the symptoms pointed
very strongly to internal strangulation. In appen^dix disease the temperature
is more frequently elevated, the vomiting is never fgecal, and in many cases
there is a history of previous attacks in the csecal region. Acute hgemorrhalgic
pancreatitis may produce symptoms which simulate closely intestinal obstruc-
tion. A boy was admitted to the Johns Hopkins Hospital with a history of
obstinate vomiting, intense abdominal pain, gradually increasing tympany,
and no passage for several days. His condition seemed serious and he was
transferred at once to the surgical wards. At the operation the coils were
found uniformly distended and covered in places with the thinnest film of
lymph. No obstruction existed, but there was a tumor-like mass surrounding
the pancreas, firm, hard, and deeply infiltrated with blood. The patient
improved after the operation and recovered completely.
Treatment. — Purgatives should not be given. For the pain hypodermic
injections of morphia are indicated. To allay the distressing vomiting, the
stomach should be washed out. ISTot only is this directly beneficial, but Kuss-
maul claims that the abdominal distention is relieved, the pressure in the
bowel above the seat of obstruction is lessened, and the violent peristalsis is
diminished. It may be practised three or four times a day, and in some in-
stances has proved beneficial; in others curative. Thorough irrigation of the
large bowel with injections should be pract-ised, the warm fluid being allowed
to flow in from a fountain syringe, and the amount carefully estimated.
Inflation may also be tried, by forcing the air into the rectum with the
bellows or with a Davidson's syringe. It is a measure not without risk, as
instances of rupture of the bowel have been reported. Of 39 cases in children
treated by inflation or enemata 16 recovered (Wiggin). In cases of acute
obstruction, surgical measures should be resorted to early.
For the tympanites turpentine stupes and hot applications may be ap-
plied ; if extreme, the bowel may be punctured with a small aspirator needle.
In cases of chronic obstruction the diet must be carefully regulated, and opium
and belladonna are useful for the paroxysmal pains. Enemata should be em-
ployed, and if the obstruction becomes complete, resort must be had to surgical
measures.
V. CONSTIPATION (Costiveness).
Definition. — Eetention of faeces from any cause.
Constipation in Adults. — The causes are varied and may be classed as
general and local.
General Causes. — (a) Constitutional peculiarities: Torpidity of the bow-
els is often a family complaint and is found more often in dark than in fair
persons. (&) Sedentary habits, particularly in persons who eat too much and
neglect the calls of nature, (c) Certain diseases, such as ansemia, neuras-
thenia and hysteria, chronic aifections of the liver, stomach, and intestines,
and the acute fevers. Under this heading may appropriately be placed that
526 DISEASES OF THE DIGESTIVE SYSTEM.
most injuiious of all habits, drug-taking, (d) Either a coarse diet, which
leaves too much residue, or a diet wliich leaves too little.
Local Causes. — Weakness of the abdominal muscles in obesity or from
overdistention in repeated pregnancies. Atony of the large bowel from chronic
disease of the mucosa; the presence of tumors, physiological or pathological,
pressing upon the bowel; enteritis; foreign bodies, large masses of scybala,
and strictures of all kinds. An important local cause is atony of the colon,
particularly of the muscles of the sigmoid flexure by which the fseces are
propelled into the rectum. By far the most obstinate form is that associated
with a contracted state of the bowel, which is sometimes spoken of as spas-
modic constipation. This may be met with in three conditions: First, as a
sequence of chronic dysentery or ulcerative colitis; secondly, in protracted
cases of hysteria and neurasthenia in women, particularly in association with
uterine disease; and, thirdly, in very old persons often without any definite
cause. It may be that the sigmoid flexure and lower colon are in a condition
of contraction and spasm, while the transverse and ascending parts are in a
state of atony and dilatation. The most characteristic sign of this variety
is the presence of hard, globular masses, or more rarely small and sausage-
like fffices. For interesting studies, with the X-rays, of the phenomena of
constipation see the articles by Hertz in the Lancet, 1908.
Symptoms. — The most persistent constipation for weeks or even months
may exist with fair health. All kinds of evils have been attributed to poison-
ing by the resorption of noxious matters from the retained faces — copramia.
Chlorosis, which Sir Andrew Clark attributed to fsecal poisoning, is not always
associated with constipation, and if due to this cause should be in men, women,
and children the most common of all disorders. Debility, lassitude, and a
mental depression are frequent s}'niptoms in constipation, particularly in per-
sons of a nervous temperament. Headache, loss of appetite, and a furred
tongue may also occur. Individuals difEer extraordinarily in this matter:
one feels wretched all day without the accustomed evacuation ; another is com-
fortable all the week except on the day on which by purge or enema the bowels
are relieved.
When persistent, the accumulation of faeces leads to unpleasant, some-
times serious symptoms, such as piles, ulceration of the colon, distention of
the sacculi, perforation, enteritis, and occlusion. In women, pressure may
cause pain at the time of menstruation and a sensation of fulness and dis-
tention in the pelvic organs. Xeuralgia of the sacral nerves may be caused
by an overloaded sigmoid flexure. The faeces collect chiefly in the colon.
Even in. extreme grades of constipation it is rare to find dry faeces in the
caecum. The fa?ces may form large tumors at the hepatic or splenic flexures,
or a sausage-like, doughy mass above the navel, or an irregular lumpy tumor
in the left inguinal region. In old persons the sacculi of the colon become
distended and the scybala may remain in them and undergo calciflcation,
forming enteroliths.
In cases with prolonged retention the faecal masses become channeled and
diarrhoea may occur for days before the true condition is discovered by rectal
or external examination. In women who have been habitually constipated,
attacks of diarrhoea with nausea and vomiting should excite suspicion and
lead to a thorough examination of the large bowel. Fever may occur in these
DISEASES OF THE INTESTINES. 527
cases, and Meigs has reported an instance in which the condition simulated
typhoid fever.
Constipation in infants is a common and troublesome disorder. The
causes are congenital, dietetic, and local. There are instances in which the
child is constipated from birth and may not have a natural movement for
years and yet thrive and develop. There are cases of enormous dilatation of
the large bowel with persistent constipation. The condition appears sometinaes
to be a congenital defect. In some of these patients there may be constricting
bands, or, as in a case of Cheever's, a congenital stricture.
Dietetic causes are more common. In sucklings it often arises from an
unnatural dryness of the small residue which passes into the colon, and it
may be very difficult to decide whether the fault is in the mother's milk or in
the digestion of the child. Most probably it is in the latter, as some babies
may be persistently costive on natural or artificial foods. Deficiency of fat
in the milk is believed by some writers to be the cause. In older children
it is of the greatest importance that regular habits should be enjoined. Care-
lessness on the part of the mother in this matter often lays the foundation of
troublesome constipation in after life. Impairment of the contractility of the
intestinal wall in consequence of inflammation, disturbance in the normal
intestinal secretions, and mechanical obstruction by tumors, twists, and intus-
susception are the chief local causes.
Treatment. — Much may be done by systematic habits, particularly in the
young. The desire to go to stool should always be granted. Exercise in
moderation is helpful. In stout persons and in women with pendulous abdo-
mens the muscles should have the support of a bandage. Friction or regu-
larly applied massage is invaluable in the more chronic cases. A good substi-
tute is a metal ball weighing from four to six pounds, which may be rolled
over the abdomen every morning for five or ten minutes. The diet should be
light, with plenty of fruit and vegetables, particularly salads and tomatoes.
Oatmeal is usually laxative, though not to all; brown bread is better than
that made from fine white flour. Of liquids, water and aerated mineral waters
may be taken freely. A tumblerful of cold water on rising, taken slowly, is
efficacious in many cases. A glass of hot water at night may also be tried
alone. A pipe or a cigar after breakfast is with many men an infallible
remedy.
When the condition is not very obstinate it is well to try to relieve it by
hygienic and dietetic measures. If drugs must be used they should be the
milder saline laxatives or the compound liquorice powder. Enemata are often
necessary, and it is much preferable to employ them early than to constantly
use purgative pills. Glycerine either in the form of suppository or as a small
injection is very valuable. Half a drachm of boric acid placed within the
rectum is sometimes efficacious. The injections of tepid water, with or with-
out soap, may be used for a prolonged period with good effect and without
damage. The patient should be in the dorsal position with the hips elevated,
and it is best to let the fluid flow in slowly from a fountain syringe.
The usual remedies employed are often useless in the constipation asso-
ciated with contracted bowel. A very satisfactory measure is the olive-oil
injection as recommended by Kussmaul. The patient lies on the back with
the hips elevated^ and with a cannula and tube from 15 to 30 ounces of pure
528 DISEASES OF THE DIGESTIVE SYSTEM.
oil are alloAved to flow slowly (or are injected) into the bowel. The opera-
tion should take at least fifteen minutes. This may be repeated every day
until the intestine is cleared, and subsequently a smaller injection every few
days will suffice.
There are various drugs which are of special service, particularly the com-
bination of ipecacuanha, nux vomica, or belladonna, with aloes, rhubarb, colo-
cyntli, or podophyllin. Meigs recommends particularly the combination of
extract of belladonna (gr. y-j)? extract of nux vomica (gr. ^), and extract of
coloc}Tith (gr. ij), one pill to be taken three times a day. In anaemia and
chlorosis, a sulphur confection taken in the morning, and a pill of iron, rhu-
barb, and aloes throughout the day, are very serviceable.
In children the indications should be met, as far as possible, by hygienic
and dietetic measures. In the constipation of sucklings a change in the diet
of the mother may be tried, or from one to three teaspoonfuls of cream may
be given before each nursing. In artificially fed children the top milk with
the cream should be used. Drinking of water, barley water, or oatmeal water
will sometimes obviate the difficulty. If laxatives are required, simple syrup,
manna, or olive oil may be sufficient. The conical piece of soap, so often seen
in nurseries, is sometimes efficacious. Massage along the colon may be tried.
Small injections of cold water may be used. Large injections should be
avoided, if possible. If it is necessary to give a laxative by the mouth, castor
oil or the fluid magnesia is the best. The saline purgatives appear to act by
increasing the muscular and glandular activit}^ of the bowel. If there are
signs of gastro-intestinal irritation, rhubarb and soda or gray powder may
be given. In older children the diet should be carefully regulated.
VI. ENTEROPTOSIS (Glenard's Disease).
Definition. — " Dropping of the viscera," visceroptosis, is not a disease, but
a symptom group characterized by looseness of the mesenteric and peritoneal
attachments, so that the stomach, the intestines, particularly the transverse
colon, the liver, the kidneys, and the spleen occupy an abnormally low position
in the abdominal cavit}'.
Symptoms and Physical Signs. — It is important to recognize two groups
of cases. In one the splanclinoptosis follows the loss of normal support of
the abdominal wall in consequence of repeated pregnancies or recurring ascites.
The condition may be extreme without the slightest distress on the part of
the patient.
The second and more important group occurs usually in young persons,
who present, with splanclinoptosis, the features of more or less marked neu-
rasthenia.
In the first group inspection of the abdomen shows a very relaxed abdom-
inal wall, and as a rule the linese albicantes of recurring pregnancies. Peri-
stalsis of the intestines may be seen, and in extreme cases the outlines of the
stomach itself with its waves of peristalsis. On inflating the stomach with
carbonic-acid gas the organ stands out with' great prominence, and the lesser
and greater curvatures are seen, the latter extending perhaps a hand's breadth
below the level of the navel. The waves of peristalsis are feeble and without
the vigor and force of those seen in the stomach dilated from stricture of the
DISEASES OF THE INTESTINES. 529
pylorus. The condition of descensus ventriculi with atony is ])est studied in
this group of cases. An important point to remember is that it may exist in
an extreme grade without symptoms.
In the other group is embraced a somewhat motley series of cases, in which,
with a pronounced nervous, or, as we call it now, neurasthenic basis, there are
displacements of the viscera with symptoms. The patients are usually young,
more frequently women than men, and of spare habit. The condition may
follow an acute illness with wasting. They complain, as a rule, of dyspepsia,
throbbing in the abdomen, and dragging pains or weakness in the back, and
inability to perform the usual duties of life. A very considerable proportion
of all the cases of neurasthenia present the local features of enteroptosis.
When preparing for the examination one notices usually an erythematous
flushing of the skin ; the scratch of the nail is followed instantly by a line of
hyperemia, less often of marked pallor. The pulsation of the abdominal
aorta is readily seen.
On examination of the viscera one finds the following: The stomach is
below the normal level, and in women who have laced it may be vertically
placed. The splashing of clapotage is unusually distinct. After inflation
with carbonic-acid gas the outlines of the stomach are seen through the thin
abdominal walls. In extreme cases there may be great dilatation of the stom-
ach, in consequence of obstruction of the pylorus by pressure of the displaced
right kidney.
Nephroptosis, or displacement of the kidney, is one of the most constant
phenomena in enteroptosis. It is well, perhaps, to distinguish between the
kidney which one can just touch on deep inspiration — palpable kidney, one
which is freely movable, and which on deep inspiration descends so that one
can put the fingers of the palpating hand above it and hold it down, and,
thirdly, a fioating kidney, which is entirely outside the costal arch, is easily
grasped in the hand, readily moved to the middle line, and low down toward
the right iliac fossa. It is held by some that the designation floating kidney
should be restricted to the cases in which there is a meso-nepliron, but this
is excessively rare, while extreme grades of renal mobility are common. Some
of the more serious sequences of movable kidney, namely, Dietl's crises and
intermittent hydronephrosis, will be considered with diseases of the kidney.
Displacement of the liver is very much less common. In thin women
who have laced the organ is often tilted forward, so that a very large sur-
face of the lobes comes in contact with the abdominal wall; it is a very com-
mon mistake under these circumstances to think that the organ is enlarged.
Dislocation of the liver itself will be considered later.
Mobility of the spleen is sometimes very marked in enteroptosis. In an
extreme grade it may be found in almost any region of the abdomen. It is
very frequently mistaken for a fibroid or ovarian tumor. A considerable pro-
portion of the cases come first under the care of the gynecologist.
There is usually much relaxation of the mesentery and of the peritoneal
folds which support the intestines. The colon is displaced downward (colop-
tosis), with consequent kinking at the flexures. The descent may be so low
that the transverse colon is at the brim of the pelvis. It may indeed be fixed
or bent in the form of a V. It is frequently to be felt, as Glenard states,
as a firm cord crossing the abdomen at or below the level of the navel. This
35
530 DISEASES OF THE DIGESTIVE SYSTEM.
kinking may take place not only in the colon, but at the pj'lorus, where the
duodenum passes into the jejunum, and where the ileum enters the csecum.
The explanation of the phenomena accompanying enteroptosis is by no
means easy. It has been suggested by Glenard and others that overfilling of
the splanchnic vessels in consequence of displacements and kinking accounts
for the feelings of exhaustion and general nervousness. In a large proportion
of the cases, however, no symptoms occur until after an illness or some pro-
tracted nervous strain.
Treatment. — In a majority of all cases four indications are present: To
treat the existing neurasthenia, to relieve the nervous dyspepsia, to overcome
the constipation, and to afford mechanical support to the organs. Three of
these are considered under their appropriate sections. In cases in which the
enteroptosis has followed loss in weight after an acute illness or worries and
cares, an important indication is to fatten the patient.
A well-adapted abdominal bandage is one of the most important measures
in enteroptosis. In many of the milder grades it alone suffices. I know of
no single simple measure which affords relief to distressing symptoms in so
many cases as the abdominal bandage. It is best made of linen, should fit
snugly, and should be arranged with straps so that it can not ride up over the
hips. A special form must be used, as will be mentioned later, for movable
kidney. Some of the more aggravated types of enteroptosis are combined
with such features of neurasthenia that a rigid Weir Mitchell treatment is
indicated. In a few very refractory cases surgical interference may be called
for. Treves, in Allbutt's System, records two cases, one in which laparotomy
was resorted to as a medical measure with perfect results. In the other the
liver was stitched in place, and complete recovery followed.
And lastly, the physician must be careful in dealing with the subjects
of enteroptosis not to lay too much stress on the disorder. It is well never
to tell the patient that a kidney is movable; the symptoms may date from
a knowledge of the existence of the condition.
VII. MISCELLANEOUS AFFECTIONS.
I. Mucous Colitis.
Known by various names, such as membranous enteritis, tubular diarrhoea,
mucous colic, and myxoneurosis intestinalis, this remarkable disease has been
recognized for several centuries. An exhaustive description of it is given by
Woodward in vol. ii of the Medical and Surgical Reports of the Civil War.
The passage of mucus in large quantities from the bowel is met with, first,
in catarrh of the intestine, due to various causes. It is not uncommon in chil-
dren, and may be associated with disturbances of digestion and slight colic.
Secondly, in local disease or irritation of the bowel, in cancer of the colon
and of the rectum. In tubo-ovarian disease much mucus and slime may be
passed. Thirdly, true mucous colitis, a secretion neurosis of the large intes-
tine met with particularly in nervous and hysterical patients. It is more com-
mon in women than in men. There is an abnormal secretion of a tenacious
mucus, which may be slimy and gelatinous, like frog-spawn, or it is passed in
strings or strips, more rarely as a continuous tubular membrane. . I have
DISEASES OF THE INTESTINES. 531
twice seen this membrane in situ, closely adherent to the mucosa, but capable
of separation without any lesion of the surface. Microscopically the casts are
mucoid, of a uniform granular ground substance through which there are rem-
nants of cells, some of which have undergone a definite hyaline transformation.
Triple phosphate, cholesterin, and fatty crystals are present, and occasionally
fine, sand-like concretions. The epithelium of the mucosa seems to be intact.
Symptoms. — In a large proportion of all the cases the subjects are nervous
in greater or less degree. Some cases have had hysterical outbreaks, and there
may be hypochondriasis or melancholia. The patients are self-centred and
often much worried about the mucous stools. Some of the cases are among
the most distressing with which we have to deal, invalids of from ten to twenty
years' standing, neurasthenic to an extreme degree, with recurring attacks of
pain and the passage of large quantities of mucus or even of intestinal casts.
In many cases the attacks may come on in paroxysms, associated with
colicky pains, or occasionally crises of the greatest severity, so that appendicitis
may be suspected. Emotional disturbances, worry of all sorts, or an error
in diet may bring on an attack. Constipation is a special feature in many
cases. Sometimes there are attacks of nervous diarrhoea.
While the disease is obstinate and distressing, it is rarely serious, though
Herringham states that he knew of three cases of mucous colitis in which
death occurred suddenly, in all with great pain in the left side of the abdomen.
The abdomen itself is rarely distended. There is often a very painful spot
just between the navel and the left costal border, tender on pressure, and some-
times the paroxysms of pain seem centred in this region.
Diagnosis. — The diagnosis is rarely doubtful, but it is important not to
mistake the membranes for other substances; thus, the external cuticle of
asparagus and undigested portions of meat or sausage-skins sometimes assume
forms not unlike mucous casts, but the microscopical examination will quickly
differentiate them. Mucous colitis with severe pain may be mistaken for
appendicitis.
Treatment. — Drugs are of little value. It is quite useless to give bismuth
and so-called intestinal remedies. First the basic neurasthenic state is to be
dealt with, and this may suffice for a cure. Secondly, daily irrigations of the
colon through a long tube — one to two pints of warm alkaline fluid. At
Plombieres, Harrogate, and other spas this treatment is most successfully
carried out. Thirdly, the coarser sorts of food should be eaten which leave
a large residue; and, lastly, should these measures fail, the question of open-
ing the colon or irrigating through the appendix may be considered.
II. Dilatation of the Colon.
Hale White, in Allbutt's System, recognizes four groups of cases. In the
first the distention is entirely gaseous, and occurs not infrequently as a tran-
sient condition. In many cases it has an important influence, inasmuch as
it may be extreme, pushing up the diaphragm and seriously impairing the
action of the heart and lungs. H. Fenwick has called attention to this as
occasionally a cause of sudden heart-failure.
In the second group are the cases in which the distention of the colon is
caused by solid substances, as faecal matter, occasionally by foreign bodies
introduced from without, and more rarely by gall-stones.
532 DISEASES OF THE DIGESTIVE SYSTEM.
"When, tliirdl}', the dilatation is due to an organic obstruction in front
of the dilated gut, the colon may reach a very large size. These cases are
common enough in malignant tumors and sometimes in volvulus. Dilata-
tion of the sigmoid flexure occurs particularly when this portion of the bowel
is congenitally very long. In such cases the bowel may be so distended that
it occupies the greater part of the abdomen, pusliing up the liver and the dia-
phragm. An acute condition is sometimes caused by a twist in the meso-colon.
Fourthly, there are the cases of so-called ideopathic dilatation of the colon,
which occurs most commonly in children. Aarchow called it " giant growth
of the colon." While, as a rule, there is no obstruction or narrowing, there may
be, as Treves has pointed out, stricture of the sigmoid flexure. In the idio-
pathic chronic form the gut reaches an enormous size. The coats may be hyper-
trophied without evidence of any special organic change in the mucosa. The
most remarkable instance has been reported by Formad. The patient, known
as the "balloon-man," aged twenty-three years at the time of his death, had
had a distended abdomen from infancy. Post mortem the colon was found
as large as that of an ox, the circumference ranging from 15 to 30 inches.
The weight with the contents was 47 pounds. In children the symptoms are
very definite — constipation, as a rule, often protracted and leading to great
distention, the coils of the bowels forming patterns. This may be followed by
periods of diarrhoea. In several of my cases the child had never had a natural
movement. The abdomen is protuberant, particularly in the upper segment,
soft, and on inspection peristalsis may be visible. The condition is, as a rule,
incurable without surgical interference. In one of my cases good results fol-
lowed the establishment of an artificial anus, but the most brilliant case is that
reported by Treves, who excised the greater part of the colon, with recovery.
III. IxTESTixAL Sand.
" Sable Intestinal." — There are two groups of cases in which sand-like
material is passed with the stools. The false, in which it is made up of the
remains of vegetable food and fruits which have resisted digestion or which
have become encrusted with earthy salts. True intestinal sand of animal
origin, gritty fine particles, usually gray or colorless, sometimes dark. It is
formed in the bowel and is made up largely of lime salts. In mucous colitis
this material may be passed at intervals for months.
IV. Diverticulitis — Perisigmoiditis.
In the lower part of the descending colon and in the sigmoid flexure
diverticula occur, sometimes congenital, sometimes acquired, most commonly
in women and in association with constipation. Of 81 cases collected by Tell-
ing, 53 were in males. They are prone to form at the site of the appendices
epiploicee. Intestinal obstruction, acute gangrene, perforation with the for-
mation of abscess, peritonitis, vesico-colic fistula, and metastatic suppuration
are occasional complications. In acute cases left-sided appendicitis is diag-
nosed, while in the chronic cases the mimicry of cancer is very close. The
cases are more common than we have heretofore supposed. Eesection of the
affected portion of the colon has been successfully performed.
DISEASES OF THE INTESTINES. 533
V. Affections of the Mesentery,
(1) Haemorrhage (hcematoma). — Instances in which the bleeding is confined
to the mesenteric tissues are rare; more commonly the condition is associated
with hsemorrhagic infiltration of the pancreas and with retroperitoneal hsemor-
rhage. It occurs in rupture of aneurisms, either of the abdominal aorta or of
the superior mesenteric arter}^, in malignant forms of the infectious fevers, as
small-pox, and, lastly, in individuals in whom no predisposing conditions exist.
(3) Affections of the Mesenteric Vessels. — (a) Aneurism (see under
Arteries).
(&) Embolism and Thrombosis. — Infarction of the Bowel. — When the
mesenteric vessels are blocked by emboli or thrombi the condition of infarc-
tion follows in the territory supplied, which may pass on to gangrene or to
perforation and peritonitis. Probably the occlusion of small vessels does not
produce any symptoms, and the circulation may be re-established. If the supe-
rior mesenteric artery is blocked the result is fatal. Endocarditis, arterio-
sclerosis, and aneurism of the aorta are the important factors in occlusion of
the arteries. In the veins the thrombosis may be primary, following infective
processes in the intestines, particularly about the appendix, or it occurs in
cachectic states. Secondary thrombosis is met with in cirrhosis of the liver,
syphilis, and pylephlebitis, or may result from the stasis caused by arterial
emboli. Jackson, Porter, and Quimby have made an exhaustive study of 30
Boston cases, and have collected 314 cases. They recognize two groups — acute
and chronic. In the former the onset is sudden, with colic, nausea, vomiting,
and a bloody diarrhoea, so that the picture is one of acute obstruction. The
abdomen becomes distended and death occurs in collapse within a few days.
In the chronic cases the onset is insidious, and there may be no symptoms
referable to the abdomen. Of the 314 cases, 64 per cent were in men. The
diagnosis is extremely difficult, and the acute cases are usually regarded as
obstruction. Exploratory operation has been made in 47 cases, 4 of which
have recovered. In J. W. Elliot's successful case 48 inches of the bowel were
resected. In the horse, infarction of the intestine is extremely common in con-
nection with the verminous aneurisms of the mesenteric arteries, and is the
usual cause of colic in this animal.
(3) Diseases of the Mesenteric Veins. — Dilatation and sclerosis occur in
cirrhosis of the liver. In instances of prolonged obstruction there may be
large saccular dilatations with calcification of the intima, as in a case of oblit-
eration of the vena portse described by me. Suppuration of the mesenteric
veins is not rare, and occurs usually in connection with pylephlebitis. The
mesentery may be much swollen and is like a bag of pus, and it is only on
careful dissection that one sees that the pus is really within channels repre-
senting extremely dilated mesenteric veins. Two of the three cases I have
seen were in connection with local appendix abscess.
(4) Disorders of the Chyle Vessels. — Varicose, cavernous, and cystic chy-
langiomata are met with in the mucosa and submucosa of the small intestine,
occasionally of the stomach. Extravasation of chyle into the mesenteric tissue
is sometimes seen. Chylous cysts are found. I saw one the size of an egg at
the root of the mesentery. Bramann records a case in a man aged sixty-three,
in which a cyst of this kind the size of a child's head was healed by operation.
534 DISEASES OF THE DIGESTIVE SYSTEM.
There is an instance on record of a congenital malformation of the thoracic
duct, in which the receptaculmn formed a flattened cyst which discharged into
the peritonaeum, and a chylous ascitic fluid was withdrawn on several occasions.
Homans, of Boston, reports an extraordinary case of a girl, who from the third
to the thirteenth year had an enlarged abdomen. Laparotomy showed a series
of cysts containing clear fluid. They were supposed to be dilated lymph ves-
sels connected with the intestines.
(5) Cysts of the Mesentery. — Much attention has been directed of late
years to the occurrence of mesenteric cysts, and the literature which is fully
given by Dowd (Annals of Surgery, vol. xxxii) is already extensive. They
may be either dermoid, hydatid, serous, sanguineous, or ch3dous. They
occur at any portion of the mesentery, and range from a few inches in diam-
eter to large masses occup3ing the entire abdomen. They are frequently
adherent to the neighboring organs, to the liver, spleen, uterus, and sigmoid
flexure.
The symptoms usually are those of a progressively enlarging tumor in the
abdomen. Sometimes a mass develops rapidly, particularly in the heemor-
rhagic forms. Colic and constipation are present in some cases. The general
health, as a rule, is well maintained in spite of the progressive enlargement of
the abdomen, which is most prominent in the umbilical region. Mesenteric
cysts may persist for many years, even ten or twenty.
The diagnosis is extremely uncertain, and no single feature is in any way
distinctive, xlugagneur gives three important signs : the great mobility, the
situation in the middle line, and the zone of tympany in front of the tumor.
Of these, the second is the only one which is at all constant, as when the
tumors are large the mobility disappears, and at this stage the intestines, too,
are pushed to one side. It is most frequently mistaken for ovarian tumor.
Movable kidney, hydronephrosis, and cysts of the omentum have also been
confused with it. In certain instances puncture may be made for diagnostic
purposes, but it is better to advise laparotomy for the purpose of drainage,
or, if possible, enucleation may be practised.
H. DISEASES OF THE LIVER.
I. JAUNDICE (Icterus).
Definition. — Jaundice or icterus is a condition characterized by coloration
of the skin, mucous membranes, and fluids of the body by the bile-pigment.
Like albuminuria, jaundice is a symptom and not a disease, and is met
with in a variety of conditions.
For a full consideration of the theories of jaundice the reader is referred
to William Hunter's article in Allbutt's System of Medicine. The cases with
icterus may be divided into three great groups.
1. Obstructive Jaundice,
The following classification of the causes of obstructive jaundice is given
by Murchison: (1) Obstruction by foreign bodies within the ducts, as gall-
DISEASES OF THE LIVER. 535
stones and parasites; (2) by inflammatory tumefaction of the duodanum or
of the lining membrane of the duct; (3) by stricture or obliteration of the
duct; (4) by tumors closing the orifice of the duct or growing in its interior;
(5) by pressure on the duct from without, as by tumors of the liver itself, of
the stomach, pancreas, kidney, or omentum; by pressure of enlarged glands
in the fissures of the liver, and, more rarely, of abdominal aneurism, faecal
accumulation, or the pregnant uterus.
According to Eolleston, in these cases of extra-hepatic or obstructive jaun-
dice the pressure within the biliary capillaries, usually low, becomes increased
"and the bile is absorbed by the lymphatics of the liver and not by the blood
capillaries.
To these causes some add lowering of the blood pressure in the portal sys-
tem so that the tension in the smaller bile-ducts is greater than in the blood-
vessels. For this view, however, there is no positive evidence. In this class
may perhaps be placed the cases of jaundice from mental shock or depressed
emotions, which " may conceivably cause spasm and reversed peristalsis of the
bile-duct" (W. Hunter).
General Symptoms of Obstructive Jaundice. — ^(1) Icterus, or tinting
of the skin and conjunctives. The color ranges from a lemon-yellow in catar-
rhal jaundice to a deep olive-green or bronzed hue in permanent obstruction.
In some instances the color of the skin is greenish black, the so-called " black
jaundice." Except the central nervous system, the tissues are all stained.
(2) In the more chronic forms pruritus is a most distressing symptom.
There is a curious preicteric itching, which Eiessman thinks is suggestive of
cancer, but I have seen it most marked in gall-stone cases. Sweating is com-
mon, and may be curiously localized to the abdomen or to the palms of the
hands. Lichen, urticaria, and boils may occur. Xanthoma multiplex is rare.
Only two cases have occurred under my observation. Usually in the flat form,
rarely nodular, they are most common in the eyelids and on the hands and
feet. They may be very numerous over the whole body. Occasionally the
tumors are found in the bile duct. After persisting for years they may dis-
appear. In very chronic cases telangiectases develop in the skin, sometimes
in large numbers over the body and face, occasionally on the mucous mem-
brane of the tongue and lips, forming patches of a bright red color from
1 to 2 cm. in breadth.
(3) The secretions are colored with bile-pigment. The sweat tinges the
linen; the tears and saliva and milk are rarely stained. The expectoration
is not often tinted unless there is inflammation, as when pneumonia coexists
with jaundice. The urine may contain the pigment before it is apparent in
the skin or conjunctiva. The color varies from light greenish yellow to a
deep black-green. Gmelin's test is made by allowing five or six drops of urine
and a similar amount of common nitric acid to flow together slowly on the
flat surface of a white plate. A play of colors is produced — various shades
of green, yellow, violet, and red. In cases of jaundice of long standing or
great intensity the urine usually contains albumin and always bile-stained
tube-casts.
(4) No bile passes into the intestine. The stools therefore are of a pale
drab or slate-gray color, and usually very fetid and pasty. The " clay-color "
of the stools is also in part due to the presence of undigested fat which,
536 DISEASES OF THE DIGESTIVE SYSTEM.
according to Miiller, may be increased from 7 to 10 per cent, which is normal,
to 55 or 78.5 per cent. There may be constipation; in many instances, owing
to decomposition, there is diarrhoea.
(5) Slow pulse. The heart's action may fall to 40, 30, or even to 20 per
minute. It is particularly noticeable in the cases of catarrhal and recent jaun-
dice, and is not as a rule an unfavorable symptom. This bradycardia has been
ascribed to the inhibitory action of the bile salts on the cardiac ganglia. It
occurs only in the early stages of jaundice. At this time bile acids pass into
the blood, but are produced in very small quantities when jaundice is estab-
lished. The respirations may fall to 10 or even to 7 per minute. Xanthopsia,
or yellow vision, may occur.
(6) Hemorrhage. The tendency to bleeding in chronic icterus is a serious
feature in some cases. It has been shown that the blood-coagulation time may
be much retarded, and instead of from three minutes and a half to four min-
utes and a half we have found it in some cases as late as eleven or twelve min-
utes. This is a point which should be taken account of by surgeons, inasmuch
as incontrollable hgemorrhage is a well-recognized accident in operating upon
patients with chronic obstructive jaundice. Purpura, large subcutaneous
extravasations, more rarely haemorrhages from the mucous membranes, occur
in protracted jaundice, and in the more severe forms.
(7) Cerebral symptoms. Irritability, great depression of spirits, or even
melancholia may be present. In any case of persistent jaundice special nerv-
ous phenomena may develop and rapidly prove fatal — such as sudden coma,
acute delirium, or con\Tilsions. Usually the patient has a rapid pulse, slight
fever, and a dry tongue, and he passes into the so-called " typhoid state."
These features are not nearly so common in obstructive as in febrile jaundice,
but they not infrequently terminate a chronic icterus in whatever way pro-
duced. The group of symptoms has been termed cholcemia or, on the supposi-
tion that cholesterin is the poison, cholestermmia ; but its true nature has not
yet been determined. In some of the cases the symptoms may be due to
uragmia.
2. Toxemic and Hemolytic Jaundice.
The term hsematogenous jaundice was formerly applied to this group in
contradistinction to the hepatogenous jaundice, associated with manifest ob-
structive changes in the bile-passages. The toxic jaundice cases are essentially
obstructive in origin, and it is doubtful whether there are any true non-obstruc-
tive cases. The manner in which the jaundice is produced in these cases has
been experimentally worked out by Stadelmann and Afanassiew. The obstruc-
tion is due to the extreme visciditv of the bile associated with a mild angio-
colitis. The sequence of events is as follows : Destruction of blood by hemoly-
sis; liberation of haemoglobin with increased formation and excretion of bile
pigments (polychromia) ; increased viscidity of the bile, which, at the low pres-
sure at which the bile is excreted, .causes a temporary obstruction, with reab-
sorption of the bile and jaundice; finally, as the drug exhausts itself, the bile
loses its viscid character, the flow is re-established, and the jaundice disappears.
Stadelmann found that a similar explanation applies to other varieties of jaun-
dice associated with increased blood destruction. To show that the blood and
liver both play a part in the production of the jaundice, Afanassiew has sug-
DISEASES OF THE LIVER. 537
gested the name '^ hremoliepatogenoiis " jaundice. Rolleston refers to them
as cases of " intrahepatic " jaundice. Hunter groups the causes as follows :
1. Jaundice produced by the action of poisons, such as toluylendiamin, phos-
phorus, arsenic, snake-venom. 2. Jaundice met with in various specific fevers
and conditions, such as yellow fever, malaria (remittent and intermittent),
pyemia, relapsing fever, typhus, enteric fever, scarlatina. 3. Jaundice met
with in various conditions of unknown but more or less obscure infective
nature, and variously designated as epidemic, infectious, febrile, malignant
jaundice, icterus gravis, Weil's disease, acute yellow atrophy.
The symptoms are not nearly so striking as in the obstructive variety.
The bile is present in the stools. The skin has in many cases only a light
lemon tint. The urine may contain no bile-pigment, but the urinary pig-
ments are considerably increased. In the severer forms, as in acute yellow
atrophy, the color may be more in-tense, but in malaria and pernicious angemia
the tint is usually light. The constitutional disturbance may be very pro-
found, with high fever, delirium, convulsions, suppression of urine, black
vomit, and cutaneous hemorrhages. In certain cases of haemolytic jaundice
the fragility of the red corpuscles is greatly increased and they may be smaller
than normal (Widal, Chautfard) and show granular degeneration. This is
particularly the case in the group of congenital icterus with enlarged spleen.
3. Hereditaey Icterus.
A family form of icterus has long been known. We must recognize, indeed,
several groups. First, icterus neonatorum, the remarkable instance described
by Glaister (Lancet, March, 1879),. in which a woman had eight children, six
of whom died of jaundice shortly after birth; one of the cases had stenosis of
the common duct, which, as Jolm Thomson has shown, is, with angiocholitis,
a common lesion in this affection. Still more remarkable is it that the mother
of the woman had twelve children, all of whom were icteric after birth, but
the jaundice gradually disappeared. A brother of the woman had several chil-
dren who also were jaundiced at birth. Glaister states that all of the children
of Morgagni, fifteen in number, had icterus neonatorum. Secondly, the con-
genital acholuric icterus. Minkowski reported eight cases in three genera-
tions. The jaundice is slight, the stools are not clay colored, the urine has no
bile pigment but contains urobilin, the general health is little if at all dis-
turbed. Splenic enlargement is a marked feature. Many cases have now been
reported of this Minkowski type, nearly all in family groups, but Chauffard
has met with a case without hereditary basis and I have seen at least one case
of the kind. In the only autopsy so far reported no special changes were
found in the liver or bile passages. Thirdly, a group of cases with enlarge-
ment of the spleen and liver and marked constitutional disturbances, dwarfing
of stature, infantilism, slight jaundice, cases which have been described as
Hanot's cirrhosis, have occurred in two or three members of a family, and the
jaundice has dated from early childhood.
In connection with the various fevers, malaria, yellow fever, and Weil's
disease jaundice has been described. Two special affections may here receive
consideration, the icterus of the new-born and acute yellow atrophy.
36
538 DISEASES OF THE DIGESTIVE SYSTEM.
II. ICTERUS NEONATORUM.
Xew-born infants are liable to jaundice^ which in some instances rapidly
proves fatal. A mild and a severe form may be recognized.
The mild or physiological icterus of the new-born is a common disease
in foundling hospitals, and is not very infrequent in private practice. In 900
consecutive births at the Sloane Maternity, icterus was noted in 300 cases
(Holt). The discoloration appears early, usually on the first or second day,
and is of moderate intensity. The urine may be bile-stained and the faeces
colorless. The nutrition of the child is not usually distijrbed, and in the
majority of cases the jaundice disappears within two weeks. This form is
never fatal. The cause of this jaundice is not at all clear. Some have attrib-
uted it to stasis in the smaller bile-ducts, jvhich are compressed by the dis-
tended radicals of the portal vein. Others hold that the jaundice is due to
the destruction of a large number of red blood-corpuscles during the first
few days after birth.
The severe form of icterus in the new-born may dejDend upon (a) con-
genital absence of the common or hepatic duct, of which there are several
instances on record; (&) congenital s}"philitic hepatitis; and (c) septic poi-
soning, associated with phlebitis of the umbilical vein. This is a severe and
fatal form, in which also hemorrhage from the cord may occur.
Curiously enough, in contradistinction to other forms, the brain and cord
may be stained yellow in icterus neonatorum, sometimes diffusely, more rarely
in definite foci corresponding to the ganglion cells which have become deeply
stained (Schmorl).
III. ACUTE YELLOW ATROPHY.
(Malignant Jaundice; Icterus Gravis.)
Definition. — Jaundice associated with marked cerebral symptoms and char-
acterized anatomically b}^ extensive necrosis of the liver-cells with reduction
in volume of the organ.
Etiology. — This is a rare disease. The first authentic description of a
case was by Ballonius, who died in 1616. Bright in 1836 described the con-
dition, and gave a good colored drawing of the liver. Of 18,000 medical
patients admitted to the Johns Hopkins Hospital in nearly sixteen years
there were only 2 cases, one white and one colored. Hunter has collected only
50 cases between 1880 and 1891: (inclusive), which brings up the total number
of recorded cases to about 250. On the other hand, a physician may see sev-
eral cases within a few years, or even within a few months, as happened to
Eeiss, who saw five cases within three months at the Charite, in Berlin. The
disease seems to be rare in the United States. It is more common in women
than in men. Of the 100 cases collected by Legg, 69 were in females ; and of
Thierfelder's 143 cases, 88 were in women. There is a remarkable associa-
tion between the disease and pregnancy, which was present in 25 of the 69
women in Legg's statistics, and in 33 of the 88 women in Thierfelder's collec-
tion. This fact probably explains its prevalence in women. It is most com-
mon between the ages of twenty and thirty, but has been met with as early as
DISEASES OF THE LIVER. 539
the fourth da}^ and the tenth month. Rolleston has collected 22 cases occurring
in the first decade. It has followed fright or profound mental emotion. In
hypertrophic cirrhosis the symptoms of a profound icterus gravis may develop,
with all the clinical features of acute yellow atrophy, including the presence
of leucin and tyrosin in the urine, and convulsions. Though the symptoms
produced hy phosphorus poisoning closely simulate those of acute yellow
atrophy, the two conditions are not identical. Acute yellow atrophy occa-
sionally occurs in syphilis. This happens of tener in women than in men.
The disease has followed a drinking bout. Various organisms, most fre-
quently the colon bacillus, have been found in the liver, but possess no causal
relationship to the disease.
Morbid Anatomy. — The liver is greatly reduced in size, looks thin and
flattened, and sometimes does not reach more than one-half or even one-third
of its normal weight. It is flabby and the capsule is wrinkled. Externally
the organ has a greenish-yellow color. On section the color may be yellowish-
brown, yellowish-red, or mottled, and the outlines of the lobules are indistinct.
The yellow and dark-red portions represent different stages of the same
process — the yellow an earlier, the red a more advanced stage. The organ
may cut with considerable firmness. Microscopically the liver-cells are seen
in all stages of necrosis, and in spots appear to have undergone complete
destruction, leaving a fatty, granular debris with pigment grains and crystals
of leucin and tyrosin. Haemorrhages occur between the liver-cells. There is
a cholangitis of the smaller bile-ducts. Marchand, MacCallum, and others have
described regenerative changes in the cases which do not run an acute course.
Eegeneration occurs in two ways : ( 1 ) From hyperplasia of pre-existing
liver-cells. Mitotic figures may be seen and the regeneration of the liver-
cells leads to the production of hyperplastic or " oedematous " nodules in the
liver, which project above the surface of the surrounding parts. (2) From
hyperplasia of the interlobular bile-ducts by means of which cells approaching
liver-cells are produced. The bile- ducts and gall-bladder are empty. Hunter
concludes that it is a toxgemic catarrh of the finer bile-ducts, similar to that
which is found after poisoning by toluylendiamin or phosphorus.
The other organs show extensive bile-staining, and there are numerous
hsemorrhages. The kidneys may show marked granular degeneration of the
epithelium, and usuall}'' there is fatty degeneration of the heart. In a major-
ity of the cases the spleen is enlarged.
Symptoms. — In the initial stage there is a gastro-duodenal catarrh, and
at first the jaundice is thought to be of a simple nature. In some instances
this lasts only a few days, in others two or three weeks. Then, severe symp-
toms set in — ^headache, delirium, trembling of the muscles, and, in some
instances, convulsions. Vomiting is a constant symptom, and blood may be
brought up. Haemorrhages occur into the skin or from the mucous surfaces ;
in pregnant women abortion may occur. With the development of the head
symptoms the jaundice usually increases. Coma sets in and gradually deepens
until death. The body temperature is variable ; in a majority of the cases the
disease runs an afebrile course, though sometimes just before death there is
an elevation. In some instances, however, there has been marked pyrexia.
The pulse is usually rapid, the tongue coated and dry, and the patient is in
3, " typhoid state." There may be an entire obliteration of the liver dulness.
540 DISEASES OF THE DIGESTIVE SYSTEM.
This is due to the flabb}^ organ falling away from the abdominal walls and
allowing the intestinal coils to take its place.
The urine is bile-stained and often contains tube-casts. Frequently albu-
minuria and occasionally albumosuria occur. Urea is markedly diminished.
There is a corresponding increase in the percentage of nitrogen present as
ammonia. Herter finds it may be increased from the normal 2 to 5 per cent
up to 17 per cent. The diminution in urea is probably partly due to the liver-
cells failing to manufacture urea from ammonia, but it may also be in part
due to organic acids seizing on the ammonia, and thus preventing the forma-
tion of urea out of the basic ammonia. Leucin and tyrosin are not constantly
present; of 23 cases collected by Hunter, in 9 neither was found; in 10 both
were present ; in 3 tyrosin only ; in 1 leucin only. The leucin occurs as rounded
disks, the tyrosin in needle-shaped crystals, arranged either in bundles or in
groups. The tyrosin may sometimes be seen in the urine sediment, but it is
best first to evaporate a few drops of urine on a cover-glass. The present view
is that the leucin and tyrosin are derived from the liver-cells themselves as a
result of their extensive destruction. In the majority of cases no bile enters
the intestines, and the stools are clay-colored. The disease is almost invariably
fatal. In a few instances recovery has been noted. I saw in Leube's clinic,
at Wiirzburg, a case which was convalescent. In 1897 Legg gave a list of 28
cases of reputed recoveries.
Diagnosis. — Jaundice with vomiting, diminution of the liver volume, de-
lirium, and the presence of leucin and tyrosin in the urine, form a character-
istic and unmistakable group of symptoms. Leucin and tyrosin are not,
however, distinctive. They may be present in cases of afebrile jaundice with
slight enlargement of the liver.
It is not to be forgotten that any severe jaundice may be associated with
intense cerebral symptoms. The clinical features in certain cases of hyper-
trophic cirrhosis are almost identical, but the enlargement of the liver, the
more constant occurrence of fever, and the absence of leucin and tyrosin are
distinguishing signs. Phosphorus poisoning may closely simulate acute yellow
atrophy, particularly in the heemorrhages, jaundice, and the diminution in the
liver volume, but the gastric symptoms are usually more marked, and leucin
and tyrosin are stated not to occur in the urine.
Treatment. — No known remedies liave any infiuence on the course of the
disease. Theoretically, efforts should be made to eliminate the toxins before
they produce their degenerative effects by free purgation and the use of sub-
cutaneous and intravenous saline injections. Gastric sedatives may be used
to allay the distressing vomiting.
IV. AFFECTIONS OF THE BLOOD-VESSELS OF THE
LIVER.
(1) Anaemia. — On the post-mortem table, when the liver looks anaemic,
as in the fatty or amyloid organ, the blood-vessels, which during life were prob-
ably well filled, can be readily injected. There are no symptoms indicative of
this condition.
(2) Hyperaemia. — This occurs in two forms, (a) Active hyperemia.
After each meal the rapid absorption by the portal vessels induces transient
DISEASES OF THE LIVER. 541
congestion of the organ, which, however, is entirely physiological'; but it is
quite possible that in persons who persistently eat and drink too much this
active hypersemia may lead to functional disturbance or, in the case of drink-
ing too freely of alcohol, to organic change. In the acute fevers an acute
hypersemia may be present.
The symptoms of active hyperaemia are indefinite. Possibly the sense
of distress or fulness in the right hypochondrium, so often mentioned by
dyspeptics and by those who eat and drink freely, may be due to this cause.
There are probably diurnal variations in the volume of the liver. In cir-
rhosis with enlargement the rapid reduction in volume after a copious haem-
orrhage indicates the important part which hypersemia plays even in organic
troubles. It is stated that suppression of the menses or suppression of a
hasmorrhoidal flow is followed by hypersemia of the liver. Andrew H. Smith
has described a case of periodical enlargement of the liver.
(&) Passive Congestion. — This is much more common and results from
an increase of pressure in the efferent vessels or sub-lobular branches of the
hepatic veins. Every condition leading to venous stasis in the right heart
at once affects these veins.
In chronic valvular disease, in emphysema, cirrhosis of the lung, and in
intrathoracic tumors mechanical congestion occurs and finally leads to very
definite changes. The liver is enlarged, firm, and of a deep-red color; the
hepatic vessels are greatly engorged, particularly the central vein in each lob-
ule and its adjacent capillaries. On section the organ presents a peculiar
mottled appearance, owing to the deeply congested hepatic and the ansemic
portal territories ; hence the term nutmeg which has been given to this condi-
tion. Gradually the distention of the central capillaries reaches such a grade
that atrophy of the intervening liver-cells is induced. Brown pigment is
deposited about the centre of the lobules and the connective tissue is greatly
increased. In this cyanotic induration or cardiac liver the organ is large in
the early stage, but later it may become contracted. Occasionally in this form
the connective tissue is increased about the lobules as well, but the process
usually extends from the sub-lobular and central veins.
The symptoms of this form are not always to be separated from those
of the associated conditions, Gastro-intestinal catarrh is usually priesent and
hsematemesis may occur. The portal obstruction in advanced cases leads to
ascites, which may precede the development of general dropsy. There is often
slight jaundice, the stools may be clay-colored, and the urine contains bile-
pigment.
On examination the organ is found to be increased in size. It may be a
full hand's breadth below the costal margin and tender on pressure. It is in
this condition particularly that we meet with pulsation of the liver. We must
distinguish the communicated throbbing of the heart, which is very common,
from the heaving, diffuse impulse due to regurgitation into the hepatic veins,
in which, when one hand is upon the ensiform cartilage and the other upon
the right side at the margin of the ribs, the whole liver can be felt to dilate
with each impulse.
The indications for treatment in passive hyperemia are to restore the
balance of the circulation and to unload the engorged portal vessels. In cases
of intense hyperaemia 18 or 20 ounces of blood may be directly aspirated from
542 DISEASES OF THE DIGESTIVE SYSTEM.
the liver, as advised hy George Harley and practised by many Anglo-Indian
physicians. Good results sometimes follow this hepato-phlebotomy. The
prompt relief and marked reduction in the volume of the organ which follow
an attack of hsematemesis or bleeding from piles suggests this practice. Salts
administered by Matthew Hay's method deplete the portal system freely and
thoroughly. As a rule, the treatment must be that of the condition with which
it is associated.
(3) Diseases of the Portal Vein. — (a) Thrombosis'; Adhesive Pyle-
phlebitis.— Coagulation of blood in the portal vein is met with in cirrhosis,
in syphilis of the liver, invasion of the vein by cancer, proliferative perito-
nitis involving the gastro-hepatic omentum, perforation of the vein by gall-
stones, and occasionally follows sclerosis of the walls of the portal vein or
of its branches (Borrmann). In rare instances a complete collateral circula-
tion is established, the thrombus undergoes the usual changes, and ultimately
the vein is represented by a fibrous cord, a condition which has been called
pyleplileiitis adliesiva. In a case of this kind which I dissected the portal vein
was represented by a narrow fibrous cord ; the collateral circulation, which must
have been completely established for years, ultimately failed, ascites and
hgematemesis supervened and rapidly proved fatal. The diagnosis of obstruc-
tion of the portal vein can rarely be made. A suggestive symptom, however,
is a sudden onset of the most intense engorgement of the branches of the
portal system, leading to ha?matemesis, melaena, ascites, and swelling of the
spleen.
Infarcts are not common in the liver and may be either anaemic or hsemor-
rhagic. They are met with in obstruction of the portal vessels, or of the portal
and hepatic veins at the same time, occasionally in disease of the hepatic artery.
(&) Suppurative pylephlebitis will be considered in the section on
abscess.
(4) Affections of the hepatic vein are extremely rare. Dilatation occurs
in cases of chronic enlargement of the right heart, from whatever cause pro-
duced. Emboli occasionally pass from the right auricle into the hepatic veins.
A rare and unusual event is stenosis of the orifices of the hepatic veins, which
I met in a case of fibroid obliteration of the inferior vena cava and wliich was
associated with a greatly enlarged and indurated liver.
(5) Hepatic Artery. — Enlargement of this vessel is seen in cases of cir-
rhosis of the liver. It may be the seat of extensive sclerosis. Aneurism of
the hepatic artery is rare, but instances are on record, and will be referred
to in the section on arteries.
V. DISEASES OF THE BILE-PASSAGES AND
GALL-BLADDER.
I. Acute Catarrh of the Bile-ducts {Catarrhal Jaundice).
Definition. — Jaundice due to swelling and obstruction of the terminal por-
tion of the common duct.
Etiology. — General catarrhal inflammation of the bile-ducts is usually asso-
ciated with gall-stones. The catarrhal process now under consideration is
probably always an extension of a gastro-duodenal catarrh, and the process is
DISEASES OF THE LIVER. 543
most intense in the pars intestinalis of the duct, which projects into the duo-
denum. The mucous membrane is swollen, and a plug of inspissated mucus
fills the diverticulum of Vater, and the narrower portion just at the orifice,
completely obstructing the outflow of bile. It is not known how wide-spread
this catarrh is in the bile-passages, and whether it really passes up the ducts.
It would, of course, be possible to have a catarrh of the finer ducts within the
liver, which some French writers think may initiate the attack, but the evi-
dence for this is not strong, and it seems more likely that the terminal por-
tion of the duct is always first involved. In the only instance which I have
had an opportunity to examine post mortem the orifice was plugged with in-
spissated mucus, the common and hepatic ducts were slightly distended and
contained a bile-tinged, not a clear, mucus, and there were no observable
changes in the mucosa of the ducts.
This catarrhal or simple jaundice results from the following causes:
(1) Duodenal catarrh, in whatever way produced, most commonly following
an attack of indigestion. It is most frequently met with in young persons,
but may occur at any age, and may follow not only errors in diet, but also
cold, exposure, and malaria, as well as the conditions associated with portal
obstruction, chronic heart-disease, and Bright's disease. (2) Emotional dis-
turbances may be followed by jaundice, which is believed to be due to catar-
rhal swelling. Cases of this kind are rare and the anatomical condition is
unknown. (3) Simple or catarrhal jaundice may occur in epidemic form.
(4) Catarrhal jaundice is occasionally seen in the infectious fevers, such as
pneumonia, and typhoid fever. The nature of acute catarrhal jaundice is
still unknown. It may possibly be an acute infection. In favor of this
view are the occurrence in epidemic form and the presence of slight fever.
The spleen, however, is not often enlarged. In only 4 out of 23 cases was it
palpable.
Symptoms. — There may be neither pain nor distress, and the patient's
friends may first notice the yellow tint, or the patient himself may observe it
in the looking-glass. In other instances there are dyspeptic symptoms and
uneasy sensations in the hepatic region or pains in the back and limbs. In the
epidemic form, the onset may be more severe, with headache, chill, and vom-
iting. Fever is rarely present, though the temperature may reach 101°, some-
times 102°. All the signs of obstructive jaundice already mentioned are pres-
ent, the stools are clay-colored, and the urine contains bile-pigment. The skin
has a bright-yellow tint ; the greenish, bronzed color is never seen in the simple
form. I have once seen spider angiomata on the face in catarrhal jaundice.
They disappeared in a few months. The pulse may be normal, but occasion-
ally it is remarkably slow, and may fall to 40 or 30 beats in the minute, and
the respirations to as low as 8 per minute. Sleepiness, too, may be present.
The liver may be normal in size, but is usually slightly enlarged, and the edge
can be felt below the costal margin. Occasionally the enlargement is more
marked. As a rule the gall-bladder can not be felt. The spleen may be in-
creased in size. The duration of the disease is from four to eight weeks.
There are mild cases in which the jaundice disappears within two weeks; on
the other hand, it may persist for three months or even longer. The stools
should be carefully watched, for they give the first intimation of removal of
the obstruction.
544 DISEASES OF THE DIGESTIVE SYSTEM.
Diagnosis. — The diagnosis is rarely difficult. The onset in young, com-
jDaratively healthy persons, the moderate grade of icterus, the absence of ema-
ciation or of evidences of cirrhosis or cancer, usually make the diagnosis easy.
Cases which persist for two or three months cause uneasiness, as the suspicion
is aroused that it may be more than simple catarrh. The absence of pain, the
negative character of the physical examination, and the maintenance of the
general nutrition are the points in favor of simple jaundice. There are
instances in which time alone can determine the true nature of the case. The
possibility of Weil's disease must be borne in mind in anomalous tj'pes.
Treatment. — As a rule the patient can keep on his feet from the outset.
Measures should be used to allay the gastric catarrh, if it is present. A dose
of calomel may be given, and the bowels kept open subsequently by salines.
The patient should not be violently purged. Bismuth and bicarbonate of soda
may be given, and the patient should drink freely of the alkaline mineral
waters, of which Yichy is the best. Irrigation of the large bowel with cold
water may be practised. The cold is supposed to excite peristalsis of the gall-
bladder and ducts, and thus aid in the expulsion of the mucus.
II. Cheoxic Cataeehal Axgiocholitis.
This may possibly occur also as a sequel of the acute catarrh. I have never
met with an instance, however, in which a chronic, persistent jaundice could
be attributed to this cause. A chronic catarrh always accompanies obstruc-
tion in the common duct, whether by gall-stones, malignant disease, stricture,
or external pressure. There are two groups of cases :
(1) With Complete Obsteuctiox of the Commox Duct. — In this form
the bile-passages are greatly dilated, the common duct may reach the size of
the thumb or larger, there is usually dilatation of the gall-bladder and of the
ducts within the liver. The contents of the ducts and of the gaU-bladder are
a clear, colorless mucus. The mucosa may be everywhere smooth and not
swollen. The clear mucus is usually sterile. The patients are the subjects
of chronic jaundice, usually without fever.
( 2 ) With Incomplete Obstbuctiox of the Duct. — There is pressure
on the duct or there are gall-stones, single or multiple, in the common duct or
in the diverticulum of Yater. The bile-passages are not so much dilated, and
the contents are a bile-stained, turbid mucus. The gall-bladder is rarely much
dilated. In a majority' of all cases stones are found in it.
The symptoms of this type of catarrhal angiocholitis are sometimes very
distinctive. With it is associated most frequently the so-called hepatic inter-
mittent fever, recurring attacks of chills, fever, and sweats. We need still
further information about the bacteriology of these cases. In aU probability
the febrile attacks are due distinctly to infection. I can not too strongly em-
phasize the point that the recmriug attacks of intermittent fever do not neces-
sarily mean suppurative angiocholitis. The question will be referred to again
under gall-stones.
III. Suppurative axd Ulcerative Angiocholitis.
The condition is a diffuse, purulent angiocholitis involving the larger and
smaller ducts. In a. large proportion of all cases there is associated suppura-
tive disease of the gall-bladder.
DISEASES OF THE LIVER. 545
Etiology. — It is the most serious of the sequels of gall-stones. Occa-
sionally a diffuse suppurative angiocholitis follows the acute infectious chole-
cystitis; this, however, is rare, since fortunately in the latter condition the
cystic duct is usually occluded. Cancer of the duct, foreign bodies, such as
lumbricoids or fish bones, are occasional causes. There may be extension from
a suppurative pylephlebitis. In rare instances suppurative cholangitis occurs
in the acute infections, as pneumonia and influenza.
The common duct is greatly dilated and may reach the size of the index
finger or the thumb ; the walls are thickened, and there may be fistulous com-
munications with the stomach, colon, or duodenum. The hepatic ducts and
their extensions in the liver are dilated and contain pus mixed with bile. On
section of the liver small abscesses are seen, which correspond to the dilated
suppurating ducts. The gall-bladder is usually distended, full of pus, and
with adhesions to the neighboring parts, or it may have perforated.
Symptoms. — The symptoms of suppurative cholangitis are usually very
severe. A previous history of gall-stones, the development of a septic fever, the
swelling and tenderness of the liver, the enlargement of the gall-bladder, and
the leucocytosis are suggestive features. Jaundice is always present, but is
variable. In some cases it is. very intense, in others it is slight. There may
be very little pain. There is progressive emaciation and loss of strength. In
a recent case parotitis developed on the left side, which subsided without sup-
puration.
Ulceration, stricture, perforation, and fistulse of the bile-passages will be
considered with gall-stones.
IV. Acute Infectious Cholecystitis.
Etiology. — Acute inflammation of the gall-bladder is usually due to bac-
terial invasion, with or without the presence of gall-stones. Three varieties or
grades may be recognized: The catarrhal, the suppurative, and the phlegmo-
nous. The condition is very serious, difficult to diagnose, often fatal, and may
require for its relief prompt surgical intervention. The cases associated with
gall-stones have of course long been recognized, but we now know that an
acute infection of the gall-bladder leading to suppuration, gangrene, or per-
foration is by no means infrequent.
Acute non-calculous cholecystitis is a result of bacterial invasion. The
colon bacillus, the typhoid bacillus, the pneumococcus and staphylococci and
streptococci have been the organisms most often found. The frequency of
gall-bladder infection in the fevers is a point already referred to, particularly
in typhoid fever.
Condition of the Gall-bladder. — The organ is usually distended and the
walls tense. Adhesions may have formed with the colon or the omentum. In
other instances perforation has taken place and there is a localized abscess,
or in the more fulminant forms general peritonitis. The contents of the
organ are usually dark in color, muco-purulent, purulent, or hemorrhagic.
In the cases with acute phlegmonous inflammation there may be a very foul
odor. As Eichardson remarks, the cystic duct is often found closed even when
no stone, is impacted. It should be borne in mind that in the acutely dis-
tended gall-bladder the elongation and enlargement may take place chiefly
upward and inward, toward the foramen of Winslow.
546 DISEASES OF THE DIGESTIVE SYSTEM.
Symptoms. — Severe paroxysmal pain is, as a rule, the first indication, most
commonly in the right side of the abdomen in the region of the liver. It
may be in the epigastrium or low down in the region of the appendix.
" Xausea, vomiting, rise of pulse and temperature, prostration, distention of
the abdomen, rigidity, general tenderness becoming localized" usually follow
(Eichardson) . In this form, without gall-stones, jaundice is not often pres-
ent. The local tenderness is extreme, but it may be deceptive in its situation.
Associated probably with the adhesion and inflammatory processes between
the gall-bladder and the bowel are the intestinal s}Tnptoms, and there may be
complete stoppage of gas and fseces; indeed, the operation for acute obstruc-
tion has been performed in several cases. The distended gall-bladder may
sometimes be felt. As sequels there may be serious distention or empyema.
Diagnosis. — The diagnosis is by no means easy. The s}Taptoms may not
indicate the section of the abdomen involved. In two of our cases and in three
of Eichardson's appendicitis was diagnosed; in two of his cases acute intes-
tinal obstruction was suspected. This was the diagnosis in a case of acute
phlegmonous cholecystitis which I reported in 1881. The history of the cases
is often a valuable guide. Occurring during the convalescence from t}^hoid
fever, after pneumonia, or in a patient with previous cholecystitis, such a
group of symptoms as mentioned would be highly suggestive. The differen-
tiation of the variety of the cholecystitis can not be made. In the acute sup-
purative and phlegmonous forms the s}Tnptoms are usually more severe, per-
foration is very apt to occur, with local or general peritonitis, and unless
operative measures are undertaken death ensues.
There is an acute cholecystitis, probably an infective form, in which the
patient has recurring attacks of pain in the region of the gall-bladder. The
diagnosis of gall-stones is made, but an operation shows simply an enlarged
gall-bladder filled with mucus and bile, and the mucous membrane perhaps
swollen and inflamed. In some of these cases gall-stones may have been pres-
ent and have passed before the operation.
V. Caxcee of the Bile-passages.
Females suffer in the proportion of 3 to 1 (Musser), or 4 to 1 (Ames).
In cases of primary cancer of the bile-duct, on the other hand, men and women
appear to be about equally affected. In Musser's series 65 per cent of the
cases occurred between the ages of forty and seventy. The association of
malignant disease of the gall-bladder with gall-stones has long been recog-
nized. The fact is well put by Kehmack as follows : " While gall-stones are
found in from 6 to 12 per cent of all general cases (that is, coming to autopsy),
they occur in association with cancer of the gall-bladder in from 90 to 100
per cent." In Futterer's series calculi were present in 70 per cent.
The exact nature of the association is not very clear, but it is usually re-
garded as an effect of the chronic irritation. On the other hand, it is urged
that the presence of the malignant disease may itself favor the production of
gall-stones. Histologically. " carcinoma of the gall-bladder varies much, both
in the form of the cells and in their structural arrangement ; it may be either
columnar or spheroidal-celled" (Eolleston). The fundus is usually first
involved in the gall-bladder, and in the ducts the ductus communis choledochus.
DISEASES OF THE LIVER. 547
When the disease involves the gall-Madder, a tumor can be detected ex-
tending diagonally downward and inward toward the navel, variable in size,
occasionally very large, due either to great distention of the gall-bladder or
to involvement of contiguous parts. It is usually very firm and hard.
Among the important symptoms are jaundice, which was present in 69
per cent of Musser's cases; pain, often of great severity and paroxysmal in
character. The pain and tenderness on pressure persist in the intervals be-
tween the paroxysmal attacks. In one of my three cases, which Ames reported,
there was a very profound anaemia, but an absence of jaundice throughout.
Gall-stones were present in two of the cases, and a history of gall-stone attacks
was obtained from the third. When the liver becomes involved the picture is
that of carcinoma of the organ.
Primary malignant disease in the tile-ducts is less common, and rarely
forms tumors that can be felt externally. The tumor is usually in the com-
mon duct, 57 of 80 cases collected by Rolleston. Kelynack gives very fully
a number- of important points in the differential diagnosis between tumors
in the duct and tumors in the gall-bladder. There is usually an early, intense,
and persistent jaundice. The dilated gall-bladder may rupture. At best the
diagnosis is very doubtful, unless cleared up by an exploratory operation. A
very interesting form of malignant disease of the ducts is that which involves
the diverticulum of Vater. Eolleston has collected 16 cases. An elderly
woman was admitted under my care with jaundice of some months' duration,
without pain, with progressive emaciation, and a greatly enlarged gall-bladder.
My colleague, Halsted, operated and found obstruction at the orifice of the
common duct. He opened the duodenum, removed a cylindrical-celled epi-
thelioma of the ampulla of Vater, and stitched the common duct to another
portion of the duodenum. The patient made an uninterrupted recovery, and,
fourteen weeks after the operation, had gained twenty-five pounds in weight
and passed bile with the faeces. A year later death occurred from secondary
disease of the head of the pancreas.
VI. Stenosis and Obstruction of the Bile-ducts.
Stenosis. — Stenosis or complete occlusion may follow ulceration, most com-
monly after the passage of a gall-stone. In these instances the obstruction is
usually situated low down in the common duct. Instances are extremely rare.
Foreign bodies, such as the seeds of various fruits, may enter the duct, and
occasionally round worms crawl into it. Liver-flukes and echinococci are rare
causes of obstruction in man.
Obstruction. — Obstruction by pressure from without is more frequent.
Cancer of the head of the pancreas, less often a chronic interstitial inflamma-
tion, may compress the terminal portion of the duct; rarely, cancer of the
pylorus. Secondary involvement of the lymph-glands of the liver is a common
cause of occlusion of the duct, and is met with in many cases of cancer of the
stomach and other abdominal organs. Rare causes of obstruction are aneu-
rism of a branch of the coeliac axis of the aorta, and pressure of very large
abdominal tumors.
Symptoms. — The symptoms produced are those of chronic obstructive jaun-
dice. At first, the liver is usually enlarged, but in chronic cases it may be
548 DISEASES OF THE DIGESTIVE SYSTEM.
reduced in size, and be found of a deepl}^ bronzed color. The hepatic inter-
mittent fever is not often associated with complete occlusion of the duct from
any cause, but it is most frequently met with in chronic obstruction by gall-
stones. Permanent occlusion of the duct terminates in death. In a majority
of the cases the conditions which lead to the obstruction are in themselves fatal.
The liver, which is not necessarily enlarged, presents a moderate grade of cir-
rhosis. Cases of cicatricial occlusion may last for years. A patient under my
care, who was permanently jaundiced for nearly three years, had a filiroid
occlusion of the duct.
Diagnosis. — The diagnosis of the nature of the occlusion is often very diffi-
cult. A history of colic, jaundice of varying intensity, paroxysms of pain, and
intermittent fever points to gall-stones. In cancerous obstruction the tumor
mass can sometimes be felt in the epigastric region. In cases in which the
lymph-glands in the transverse fissure are cancerous, the primary disease may
be in the pelvic organs or the rectum, or there may be a limited cancer of the
stomach, which has not given any s}Tnptoms. In these cases the examination
of the other l}Tnphatic glands may be of value. In a man who came under
observation with a jaundice of seven weeks' duration, believed to be catarrhal
(as the patient's general condition was good and he was not said to have lost
flesh), a small nodular mass was detected at the navel, which on removal
proved to be scirrhus. Involvement of the clavicular groups of l}Tnph-glands
may also be serviceable in diagnosis. The gall-bladder is usually enlarged in
obstruction of the common duct, except in the cases of gall-stones (Courvoi-
sier's law). Great and progressive enlargement of the liver with jaundice
and moderate continued fever is more commonly met with in cancer.
Congenital obliteration of the ducts is an interesting condition, of which
there are some 60 or 70 cases on record. It may occur in several members
of one family. Spontaneous haemorrhages are frequent, particularly from the
navel. The subjects may live for three or even eight weeks. The liver is usu-
ally cirrhotic and the spleen is enlarged. Eolleston suggests that the disease
is primarily a congenital cirrhosis with consecutive involvement of the ducts.
For a recent careful consideration of the subject, see John Thomson's article
in AUbutt's System of Medicine.
VI. CHOLELITHIASIS.
No chapter in medicine is more interesting than that wMeh deals with the
question of gall-stones. Few afEections present so many points for study —
chemical, bacteriological, pathological, and clinical. The past few years have
seen a great advance in our knowledge in two directions: First, as to the mode
of formation of the stones, and, secondly, as to the surgical treatment of the
cases. The recent study of the origin of stones dates from ISTaumTi's work in
1891. Marion Sims's suggestion that gall-stones came within the sphere of
the surgeon has been most fruitful.
Origin of Gall-stones. — Two important points with reference to the for-
mation of calculi in the bile-passages were brought out by Xaumm: (a) The
origin of the cholesterin of the bile, as well as of the lime salts from the mu-
cous membrane of the biliary passages, particularly when inflamed ; and ( & )
the remarkable association of micro-organisms with gall-stones. It is stated
DISEASES OF THE LIVER. 549
that Bristowe first noticed the origin of cholesterin in the gall-bladder itself,
but Naunyn's observations showed that both the cholesterin and the lime were
in great part a production of the mucosa of the gall-bladder and of the bile-
ducts, particularly when in a condition of catarrhal inflammation excited by
the presence of microbes. According to the views of this author, the lithoge-
nous catarrh (which, by the way, is quite an old idea) modifies materially the
chemical constitution of the bile and favors the deposition about epithelial
debris and bacteria of the insoluble salts of lime in combination with the bili-
rubin, Welch and others have demonstrated the presence of micro-organisms
in the centre of gall-stones. Three additional points of interest may be re-
ferred to :
First, the demonstration that the gall-bladder is a peculiarly favorable
habitat for micro-organisms. The colon bacilli, staphylococci, streptococci,
pneumococci, and the typhoid bacilli have all been found here under varying
conditions of the bile. A remarkable fact is the length of time that they may
live in the gall-bladder, as was first demonstrated by Blachstein in Welch's
laboratory. The typhoid bacillus has been isolated in pure culture seven years
after an attack.
Secondly, the experimental production of gall-stones has been successfully
accomplished by Gilbert and Fournier by injecting micro-organisms into the
gall-bladder of animals.
Thirdly, the association of gall-stones with the specific fevers. Bernheim,
in 1889, first called attention to the frequency of gall-stone attacks after
typhoid. Since that time Dufort has collected a series of cases, and Chiari,
Mason, and Camac have called attention to the great frequency of gall-bladder
complications during and after this disease.
While it is probable that a lithogenous catarrh, induced by micro-organ-
isms, is the most important single factor, there are other accessory causes of
great moment.
Country. — Gall-stones are less frequent in the United States than in Ger-
many, 6.94 to 13 per cent (Mosher). They are less common in England than
on the Continent. Cholelithiasis is found in India.
Age. — Nearly 50 per cent of all the cases occur in persons above forty
years of age. They are rare under twenty-five. They have been met with in
the new-born, and in infants (John Thomson).
Sex. — Three-fourths of the cases occur in women. Pregnancy has an im-
portant influence. Naunyri states that 90 per cent of women with gall-stones
have borne children.
All conditions which favor stagnation of bile in the gall-bladder predispose
to the formation of stones. Among these may be mentioned corset-wearing,
enteroptosis, nephroptosis, and occupations requiring a " leaning forward "
position. Lack of exercise, sedentary occupations, particularly when com-
bined with over-indulgence in food, constipation, depressing mental emotions
are also to be regarded as favoring circumstances. The belief prevailed for-
merly that there was a lithiac diathesis closely allied to that of gout.
Physical Characters of Gall-stones. — They may be single, in which case
the stone is usually ovoid and may attain a very large size. Instances are on
record of gall-stones measuring more than 5 inches in length. They may be
extremely numerous, ranging from a score to several hundreds or even several
550 DISEASES OF THE DIGESTIVE SYSTEM.
thousands, in which case the stones are very small. When moderately numer-
ous, they show signs of mutual pressure and have a polygonal form, with
smooth facets; occasionally, however, five or six gall-stones of medium size
are met with in the bladder which are round or ovoid and without facets.
They are sometimes mulberry-shaped and very dark, consisting largely of bile-
pigments. Again there are small, black calculi, rough and irregular in shape,
and varying in size from grains of sand to small shot. These are sometmies
known as gall-sand. On section, a calculus contains a nucleus, which consists
of bile-pigment, rarely a foreign body. The greater portion of the stone is
made up of cholesterin, which may form the entire calculus and is arranged
in concentric laminae showing also radiating lines. Salts of lime and mag-
nesia, bile acids, fattv' acids, and traces of iron and copper are also found in
them. Host gall-stones consist of from 70 to 80 per cent of cholesterin, in
either the amorjDhous or the crystalline form. As above stated, it is sometimes
jDure, but more commonly it is mixed with the bile-pigment. The outer layer
of the stone is usually harder and brownish in color.
The Seat of Formation. — "Within the liver itself calculi are occasionally
found, but are here usually small and not abundant, and in the form of ovoid,
greenish-black grains. A large majority of all calculi are formed within the
gall-bladder. The stones in the larger ducts have usually had their origin in
the gall-bladder.
Symptoms. — In a majority of the cases, gall-stones cause no s}-mptoms.
The gall-bladder will tolerate the presence of large numbers for an indefinite
period of time, and post-mortem examinations show that they are present in
25 per cent of all women over sixty years of age (Xaumm). Moynihan claims
that in most cases there are early spnj^foms — a sense of fulness, weight, and
oppression in the epigastrium; a catch in the breath, a feeling of faintness
or nausea, and a chilliness after eating. Attacks of indigestion are common.
I have seen two cases with obstinate attacks of urticaria. I have had many
cases in which the most careful inquiry failed to elicit the existence of any
s^mjjtoms prior to the attack of colic.
The French writers have suggested a useful division, dealing with the main
symptoms of cholelithiasis, into (1) the aseptic, mechanical accidents in con-
sequence of migration of the stone or of obstruction, either in the ducts or in
the intestines; (2) the septic, infectious accidents, either local (the angio-
cholitis and cholecystitis with empyema of the gall-bladder, and the fistulse
and abscess of the liver and infection of the neighboring parts) or general,
the biliary fever and the secondary visceral lesions.
1. Biliary Colic. — Gall-stones may become engaged in the cystic or the
common duct without producing pain or severe s}inptoms. More commonly
the passage of a stone excites the violent s}inptoms known as biliary colic. The
attack sets in abruptly with agonizing pain in the right hypochondriac region,
which radiates to the shoulder, or is very intense in the epigastric and in the
lower thoracic regions. It is often associated with a rigor and a rise in tem-
perature from 102° to 103°. The pain is usually so intense that the patient
rolls about in agony. There are vomiting, profuse sweating, and great depres-
sion of the circulation. There may be marked tenderness in the region of the
liver, which may be enlarged, and the gall-bladder may become palpable and
very tender. In other cases the fever is more marked. The spleen is enlarged
DISEASES OF THE LIVER. 551
(Naunyn) and the urine contains albumin with red blood-corpuscles. Ortner
holds that cholecystitis acuta, occurring in connection with gall-stones, is a
septic (bacterial) infection of the bile-passages. The symptoms of acute infec-
tious cholecystitis and those of what we call gall-stone colic are very similar,
and surgeons have frequently performed cholecystotomy for the former condi-
tion, believing calculi were present. In a large number of the cases jaundice
occurs, but it is not a necessary symptom. Of course it does not happen dur-
ing the passage of the stone through the cystic duct, but only when it becomes
lodged in the common duct. The pain is due (a) to the slow progress in the
cystic duct, in which the stone takes a rotary course owing to the arrangement
of the Heisterian valve; the cystic duct is poor in muscle fibres but rich in
nerves and ganglia; (&) to the acute inflammation which usually accompanies
an attack; (c) to the stretching and distention of the gall-bladder by retained
secretions.
The attack varies in duration. It may last for a few hours, several days,
or even a week or more. If the stone becomes impacted in the orifice of the
common duct, the jaundice becomes intense; much more commonly it is a
slight transient icterus. The attack of colic may be repeated at intervals for
some time, but finally the stone passes and the symptoms disappear.
Occasionally accidents occur, such as rupture of the duct with fatal peri-
tonitis. Fatal syncope during an attack, and the occurrence of repeated con-
vulsive seizures have come under my observation. These are, however, rare
events. Palpitation and distress about the heart may be present, and occa-
sionally a mitral murmur occurs during the paroxysm, but the cardiac condi-
tions described by some writers as coming on acutely in biliary colic are possi-
bly pre-existent in these patients.
The diagnosis of acute hepatic colic is generally easy. The pain is in the
upper abdominal and thoracic regions, whereas the pain in nephritic colic is
in the lower abdomen. A chill, with fever, is much more frequent in biliary
colic than in gastralgia, with which it is liable, at times, to be confounded.
A history of previous attacks is an important guide, and the occurrence of
jaundice, however slight, determines the diagnosis. To look for the gall-stones,
the stools should be thoroughly mixed with water and carefully filtered through
a narrow-meshed sieve. Pseudo-biliary colic is not infrequently met with in
nervous women, and the diagnosis of gall-stones made. This nervous hepatic
colic may be periodical ; the pain may be in the right side and radiating ; some-
times associated with other nervous phenomena, often excited by emotion, tire,
or excesses. The liver may be tender, but there are neither icterus nor inflam-
matory conditions. The combination of colic and jaundice, so distinctive of
gall-stones, is not always present. The pains may be not colicky, but more
constant and dragging in character. Of 50 cases operated upon by Eiedel, 10
had not had colic, only 14 presented a gall-bladder tumor, while a majority
had not had jaundice. A remarkable xanthoma of the bile-passages has been
found in association with hepatic colic. I have already spoken of the diagno-
sis of acute cholecystitis from appendicitis and obstruction of the bowels. Ee-
eurring attacks of pain in the region of the liver may follow adhesions between
the gall-bladder and adjacent parts.
2. Obstruction of the Cystic Duct. — The effects may be thus enumer-
ated :
552 DISEASES OF THE DIGESTIVE SYSTEM.
(a) Dilatation of the gall-ljladder — hydrops vesicae felles. In acute ob-
struction the contents are bile mixed with much mucus or muco-purulent mate-
rial. In chronic obstruction the bile is replaced by a clear fluid mucus. This
is an important point in diagnosis, jjarticularly as a dropsical gall-bladder may
form a very large tumor. The reaction is not always constant. It is either
alkaline or neutral; the consistence is thin and mucoid. Albumin is usually
present. A dilated gall-bladder may reach an enormous size, and in one in-
stance Tait found it occupying the greater part of the abdomen. In such
eases, as is not unnatural, it has been mistaken for an ovarian tumor. I have
described a case in which it was attached to the right broad ligament. The
dilated gall-bladder can usually be felt below the edge of the liver, and in many
instances it has a characteristic outline like a gourd. An enlarged and relaxed
organ may not be palpable, and in acute cases the distention may be upward
toward the hilus of the liver. The dilated gall-bladder usually projects directly
downward, rarely to one side or the other, though occasionally toward the mid-
dle line. It may reach below the navel, and in persons with thin walls the
outline can be accurately defined. Eiedel has called attention to a tongue-like
projection of the anterior margin of the right lobe in connection with enlarged
gall-bladder. It is to be remembered that distention of the gall-bladder may
occur without jaundice; indeed, the greatest enlargement has been met with
in such cases.
Gall-stone crepitus may be felt when the bladder is very full of stones and
its walls not very tense. It is rarely well felt unless the abdominal walls are
much relaxed. It may be found in patients who have never had any symptoms
of cholelithiasis.
(&) Acute cholecystitis. The simple form is common, and to it are due
probably very many of the symptoms of the gall-stone attack. Phlegmonous
cholecystitis is rare; only seven instances are found in the enormous statis-
tics of Courvoisier. It is, however, much more common than these figures
indicate. Perforation may occur with fatal peritonitis.
(c) Suppurative cholecystitis, empyema of the gall-bladder, is much more
common, and in the great majority of cases is associated with gall-stones — 41
m 55 cases (Courvoisier). There may be enormous dilatation, and over a litre
of pus has been found. Perforation and the formation of abscesses in the
neighborhood are not uncommon.
(d) Calcification of the gall-bladder is commonly a termination of the
previous condition. There are two separate forms : incrustation of the mucosa
with lime salts and the true infiltration of the wall with lime, the so-called
ossification.
(e) Atrophy of the gall-bladder. This is by no means uncommon. The
organ shrinks into a small fibroid mass, not larger, perhaps, than a good-sized
pea or walnut, or even has the form of a narrow fibrous string ; more com-
monly the gall-bladder tightly embraces a stone. This condition is usually
preceded by hydrops of the bladder.
Occasionally the gall-bladder presents diverticula^ which may be cut ofE
from the main portion, and usually contain calculi.
(3) Obstruction of the Common Duct. — There may be a single stone
tightly wedged in the duct in any part of its course, or a series of stones,
sometimes extending into both hepatic and cystic ducts, or a stone lies in
DISEASES OF THE LIVER. 553
the diverticulum of Vater. There are three groups of cases: (ft) In rare in-
stances a stone tightly corks the common duct, causing permanent occlusion;
or it may partly rest in the cystic duct, and may have caused thickening of
the junction of the ducts; or a big stone may compress the hepatic or upper
part of the common duct. The jaundice is deep and enduring, and there are
no septic features. The pains, the previous attacks of colic, and the absence
of enlarged gall-bladder help to separate the condition from obstruction by
new growths, although it can not be differentiated with certainty. The ducts
are usually much dilated and everywhere contain a clear mucoid fluid.
(&) Incomplete obstruction, with infective cholangitis. There may be a
series of stones in the common duct, a single stone which is freely movable,
or a stone (ball- valve stone) in the diverticulum of Vater. These conditions
may be met with at autopsy, without the subjects having had symptoms point-
ing to gall-stones; but in a majority of cases there are very characteristic
features.
The common duct may be as large as the thumb; the hepatic duct and
its branches through the liver may be greatly dilated, and the distention may
be even apparent beneath the liver capsule. Great enlargement of the gall-
bladder is rarer. The mucous membrane of the ducts is usually smooth and
clear, and the contents consist of a thin, slightly turbid bile-stained mucus.
Naunyn has given the following as the distinguishing signs of stone in
the common duct: " (1) The continuous or occasional presence of bile in
the fseces; (2) distinct variations in the intensity of the jaundice; (3) normal
size or only slight enlargement of the liver; (4) absence of distention of the
gall-bladder; (5) enlargement of the spleen; (6) absence of ascites; (7) pres-
ence of febrile disturbance; and (8) duration of the jaundice for more than
a year."
In connection with the ball-valve stone, which is most commonly found
in the diverticulum of Vater, though it may be in the common duct itself,
there is a special symptom group: (a) Ague-like paroxysms, chills, fever, and
sweating; the hepatic intermittent fever of Charcot; (&) jaundice of varying
intensity, which persists for months or even years, and deepens after each par-
oxysm; (c) at the time of the paroxysm, pains in the region of the liver with
gastric disturbance. These symptoms may continue on and off for three or
four years, without the development of suppurative cholangitis. In one of
my cases the jaundice and recurring hepatic intermittent fever existed from
July, 1879, until August, 1882; the patient recovered and still lives. The
condition has lasted from eight months to three years. The rigors are
of intense severity, and the temperature rises to 103° or 105°. The chills
may recur daily for weeks, and present a tertian or quartan type, so that
they are often attributed to malaria, with which, however, they have no con-
nection. The jaundice is variable, and deepens after each paroxysm. The
itching may be most intense. Pain, which is sometimes severe and colicky,
does not always occur. There may be marked vomiting and nausea. As a
rule there is no progressive deterioration of health. In the intervals between
the attacks the temperature is normal.
The clinical history and the post-mortem examinations in my cases show
conclusively that this condition may persist for years without a trace of sup-
puration within the ducts, There must, however, be an infection, such as may
554 DISEASES OF THE DIGESTIVE SYSTEM.
exist for years in the gall-bladder, without causing suppuration. It is prob-
able that the toxic symptoms develop only when a certain grade of tension
is reached.
An interesting and valuable diagnostic point is the absence of dilatation
of the gall-bladder in cases of obstruction from stone — Courvoisier's rule.
Ecklin, who has recently reviewed this j)oint, finds that of 172 cases of obstruc-
tion of the common duct by calculus in 34 the gall-bladder was normal, in 110
it was contracted, and in 38 it was dilated. Of 139 cases of occlusion of the
common duct from other causes the gall-bladder was normal in 9, shrunken
in 9, and dilated in 121.
(c) Incomplete obstruction^ with suppurative cholangitis. When suppu-
rative cholangitis exists the mucosa is thickened, often eroded or ulcerated;
there may be extensive suppuration in the ducts throughout the liver, and even
empyema of the gall-bladder. Occasionally the suppuration extends beyond
the ducts, and there is localized liver abscess, or there is perforation of the
gall-bladder with the formation of abscess between the liver and stomach.
Clinically it is characterized by a fever which may be intermittent, but
more commonly is remittent and without prolonged intervals of apyrexia.
The jaundice is rarely so intense, nor do we see the deepening of the color
after the paroxysms. There is usually greater enlargement of the liver, and
tenderness and more definite signs of septicaemia. The cases run a shorter
course, and recovery never takes place.
(4) The Moee Eemote Effects of Gall-stones. — (a) Biliary Fistulce.
These are not uncommon. There may, for instance, be abnormal communica-
tion between the gall-bladder and the hepatic duct or the gall-bladder and a
cavity in the liver itself. More rarely perforation occurs between the common
duct and the portal vein. Of this there are at least four instances on record,
among them the celebrated case of Ignatius Loyola. Perforation into the
abdominal cavity is not uncommon; 119 cases exist in the literature (Cour-
voisier), in 70 of which the rupture occurred directly into the peritoneal cav-
ity; in 49 there was an encapsulated abscess. Perforation may take place
from an intrahepatic branch or from the hepatic, common, or cystic ducts.
Perforation from the gall-bladder is the most common.
Fistulous communications between the bile-passages and the gastro-intes-
tinal canal are frequent. Openings into the stomach are rare. Between the
duodenum and bile-passages they are much more common. Courvoisier has
collected 10 instances of communication between the ductus communis and
the duodenum, and 73 cases between the gall-bladder and the duodenum.
Communication with the ileum and jejunum is extremely rare. Of fistulous
opening into the colon 39 cases are on record. These communications can
rarely be diagnosed; they may be present without any symptoms whatever.
It is probably by ulceration into the duodenum or colon that the large gall-
stones escape.
Occasionally the urinary passages may be opened into and the stones may
be found in the bladder. Many instances are on record of fistulae between
the bile-passages and the lungs. Courvoisier has collected 24 cases, to which
list J. E. Graham has added 10, including 2 cases of his own. (Trans, of
Assoc, of Am. Physicians, xiii.) Bile may be coughed up with the expec-
toration, sometimes in considerable quantities.
DISEASES OF THE LIVER. 555
Of all fistulous communications the external or cutaneous is the most com-
mon. Courvoisier's statistics number 184 cases, in 50 per cent of which the
perforation took place in the right hypochondrium ; in 39 per cent in the
region of the navel. The number of stones discharged varied from one or
two to many hundreds. Eecovery took place in 78 cases; some with, some
without operation.
(h) Obstruction of the Bowel ly Gall-stones. — Reference has already been
made to this; its frequency appears from the fact that of 295 cases of obstruc-
tion, occurring during eight years, analyzed by Fitz, 23 were by gall-stone.
Courvoisier's statistics give a total number of 131 cases, in 6 of which the
calculi had a peculiar situation, as in a diverticulum or in the appendix. Of
the remaining 125 cases, in 70 the stone was spontaneously passed, usually
with severe symptoms. The post-mortem reports show that in some of these
cases even very large stones have passed per viam naturalem, as the gall-duct
has been enormously distended, its orifice admitting the finger freely. This,
however, is extremely rare. The stones have been found most commonly in
the ileum.
Treatment of Gall-stones and their Effects. — In an attack of biliary colic
the patient should be kept under morphia, given hypodermically, in quarter-
grain doses. In an agonizing paroxysm it is well to give a whiff or two of chlo-
roform until the morphia has had time to act. Great relief is experienced
from the hot bath and from fomentations in the region of the liver. The
patient should be given laxatives and should drink copiously of alkaline
mineral waters. Olive oil has proved useless in my hands. When taken in
large quantities, fatty concretions are passed with the stools, which have been
regarded as calculi; and concretions due to eating pears have been also mis-
taken, particularly when associated with colic attacks. Since the days of
Durande, whose mixture of ether and turpentine is still largely used in France,
various remedies have been advised to dissolve the stones within the gall-blad-
der, none of which are efficacious.
The diet should be regulated, the patient should take regular exercise and
avoid, as much as possible, the starchy and saccharine foods. The soda salts
recommended by Prout are believed to prevent the concentration of the bile
and the formation of gall-stones. Either the sulphate or the phosphate may
be taken in doses of from 1 to 2 drachms daily. For the intolerable itching
McCall Anderson's dusting powder may be used : starch, an ounce ; camphor,
a drachm and a half; and oxide of zinc, half an ounce. Some of this should
be finely dusted over the skin with a powder-puff. Powdering with starch,
strong alkaline baths (hot), pilocarpin hypodermically (gr. i— g), and anti-
pyrin (gr. viij), may be tried. Ichthyol and lanolin ointment sometimes gives
relief.
Exploratory pimcture, as practised by the elder Pepper, in 1857, in a ease of
empyema of the gall-bladder, and by Bartholow in 1878 is not now often done.
Aspiration is usually a safe procedure, though a fatal result has followed.
The surgical treatment of gall-stones has of late years made rapid prog-
ress. The operation of cholecystotomy, or opening the gall-bladder and remov-
ing the stones, which was advised by Sims, has been remarkably successful.
The removal of the gall-bladder, cholecystectomy, has also been practised with
success. The indications for operation are : (a) Repeated attacks of gall-stone
556 DISEASES OF THE DIGESTIVE SYSTEM.
colic. The operation is now attended with such slight risk that the patient
is much safer in the hands of a surgeon than when left to Xature, with the
feeble assistance of drugs and mineral waters. (&) The presence of a dis-
tended gall-bladder, associated with attacks of pain or with fever, (c) When
a gall-stone is permanently lodged in the common duct, and the group of
symptoms above described are present, the question, then, of advising opera-
tion depends largely upon the personal methods and success of the surgeon
who is available.
In 1,000 consecutive operations for gall-stone disease the brothers Mayo,
of Eochester, Minn., had 50 deaths, 5 per cent. In 673 cases of cholecystot-
omy the mortality was only 2.4 per cent. In 186 cholecystectomies the mor-
tality was 4.3 per cent. In 137 operations for stone in the common duct the
mortality was 11 per cent.
Vn. THE CIRRHOSES OF THE LIVER.
General Considerations. — The many forms of cirrhoses of the liver have
one feature in common — an increase in the connective tissue of the organ.
In fact, we use the term cirrhosis (by which Laennec characterized the tawn}",
yellow color of the common atrophic form) to indicate similar changes in
other organs.
The cirrhoses may be classified, etiologically, according to the supposed
causation; anatomically, according to the structure primarily involved; or
clinically, according to certain special symptoms.
Etiological Classification. — 1. Toxic Cirrhosis. — Alcohol is the chief cause
of cirrhosis of the liver. Other poisons, such as lead and the toxic products
of faulty metabolism in gout, diabetes, rickets, and indigestion, play a minor
role.
2. Infectious Cirrhoses. — With many of the specific fevers necrotic
changes occur in the liver which, when wide-spread, may be followed by cirrho-
sis. Possibly the h}^ertrophic cirrhosis of Hanot and other forms met with
in early life are due to infection. The malarial cirrhosis is a well-recognized
variety. The S3^hilitic poison produces a very characteristic form.
3. Cirrhosis from chronic congestion of the Mood-vessels in heart-disease
—the cardiac liver.
4. Cirrhosis from chronic obstruction of the lile-ducts, a form of very
slight clinical interest. In anthracosis the carbon pigment may reach the liver
•in large quantities and be deposited in the connective tissue about the portal
canal, leading to cirrhosis (Welch).
Anatomical Classification. — 1. Vascular cirrhoses, in which the new
growth of connective tissue has its starting point about the finer branches of
the portal or hepatic veins.
2. Biliary cirrhoses, in which, the process is supposed to begin about the
finer bile-ducts, as in the hypertrophic cirrhosis of Hanot and in the form from
obstruction of the larger ducts.
3. Capsular cirrhoses, a perihepatitis leading to great thickening of the cap-
sule and reduction in the volume of the liver.
Clinical Classification. — For practical purposes we may recognize the fol-
lowing' varieties of cirrhosis of the liver :
DISEASES OF THE LIVER. 557
1. The alcoholic cirrhosis of Laennec, including with this the fatty cir-
rhotic liver.
2. The hypertrophic cirrhosis of Hanot.
3. Syphilitic cirrhosis.
4. Capsular cirrhosis — chronic perihepatitis.
Other forms, of slight clinical interest, are considered elsewhere under dia-
betes, malaria, tuberculosis, and heart-disease. The cirrhosis from malaria,
upon which the French writers lay so much stress (one describes thirteen vari-
eties ! ) , is excessively rare. In our large experience with malaria during the
past fifteen years not a single case of advanced cirrhosis due to this cause has
been seen in the wards or autopsy-room of the Johns Hopkins Hospital.
I. Alcoholic Cirrhosis.
Etiology. — The disease occurs most frequently in middle-aged males who
have been addicted to drink. Whisky, gin, and brandy are more potent to
cause cirrhosis than beer. It is more common in countries in which strong
spirits are used than in those in which malt liquors are taken. Among 1,000
autopsies in my colleague Welch's department of the Johns Hopkins Hospital
there were 63 cases of small atrophic liver, and 8 cases of the fatty cirrhotic
organ. Lancereaux claims that the vin ordinaire of France is a common cause
of cirrhosis. Of 210 cases, excess in wine alone was present in 68 cases. He
thinks it is the sulphate of potash in the plaster of Paris used to give the
" dry " flavor which damages the liver.
Cirrhosis of the liver in young children is not very rare. Palmer Howard
collected 63 cases, to which Hatfield added 93 and Musser 529. In a certain
number of the cases there is an alcoholic history, in others syphilis has been
present, while a third group, due to the poisons of the infectious diseases,
embraces a certain number of the cases of Hanot's hypertrophic cirrhosis.
Morbid Anatomy. — Practically on the post-mortem table we see alcoholic
cirrhosis in two well-characterized forms :
The Atrophic Cirrhosis of Laennec. — The organ is greatly reduced in
size and may be deformed. The weight is sometimes not more than a pound
or a pound and a half. It presents numerous granulations on the surface;
is firm, hard, and cuts with great resistance. The substance is seen to be
made up of greenish-yellow islands, surrounded by grayish-white connective
tissue. W. G-. MacCallum has shown that regenerative changes in the cells
are almost constantly present. This yellow appearance of the liver induced
Laennec to give to the condition the name of cirrhosis. Apart from the fatty
liver there may be enlargement as pointed out by Foxwell and Eolleston.
The Fatty Cirrhotic Liver. — Even in the atrophic form the fat is in-
creased, but in typical examples of this variety the organ is not reduced in
size, but is enlarged, smooth or very slightly granular, anaemic, yellowish-white
in color, and resembles an ordinary fatty liver. It is, however, firm, cuts with
resistance, and microscopically shows a great increase in the connective tissue.
This form occurs most frequently in beer- drinkers.
The two essential elements in cirrhosis are destruction of liver-cells and
obstruction to the portal circulation.
In an autopsy on a case of atrophic cirrhosis the peritongeum is usually
found to contain a large quantity of fluid, the membrane is opaque, and there
558 DISEASES OF THE DIGESTIVE SYSTEM.
is chronic catarrh of the stomach and of the small intestines. The spleen is
enlarged, in part, at least, from the chronic congestion, possibly due in part
to a " vital reaction,"' to a toxic influence (Parkes Weber). The pancreas fre-
quently shoTTs chronic interstitial changes. The kidneys are sometimes cir-
rhotic, the bases of the lungs may be much compressed by the ascitic fluid, the
heart often shows marked degeneration, and arterio-sclerosis is usually present.
A remarkable feature is the association of acute tuberculosis with cirrhosis.
In seven cases of my series the patients died with either acute tuberculous peri-
tonitis or acute tuberculous pleurisy. EoUeston has found that tuberculosis
was present in 28 per cent of 706 fatal cases of cirrhosis. Peritoneal tuber-
culosis was found in 9 per cent of a series of 584 cases.
The compensatory circulation is usually readily demonstrated. It is car-
ried out by the following set of vessels : ( 1 ) The accessory portal system of
Sappey, of which important branches pass in the round and suspensory liga-
ments and unite with the epigastric and mammary systems. These vessels
are numerous and small. Occasionally a large single vein, which may attain
the size of the little finger, passes from the hilus of the liver, follows the round
ligament, and joins the epigastric veins at the navel. Although this has the
position of the umbilical vein, it is usually, as Sappey showed, a para-umbil-
ical vein — that is, an enlarged vera by the side of the obliterated umbilical
vessel. There may be produced about the navel a large bunch of varices, the
so-called caput Medusa. Other branches of this system occur in the gastro-
epiploic omentum, about the gall-bladder, and, most important of all, in the
suspensory ligament. These latter form large branches, which anastomose
freely with the diaphragmatic veins, and so unite with the vena azygos. (2)
By the anastomosis between the oesophageal and gastric veins. The veins at
the lower end of the oesophagus may be enormously enlarged, producing varices
which project on the mucous membrane. (3) The communications between
the hsemorrhoidal and the inferior mesenteric veins. The freedom of com-
munication in this direction is very variable, and in some instances the hsem-
orrhoidal veins are not much enlarged, (-i) The veins of Retzius, which unite
the radicles of the portal branches in the intestines and mesentery with the
inferior vena cava and its branches. To this system belong the whole group
of retroperitoneal veins, which are in most instances enormously enlarged,
particularly about the kidneys, and which serve to carry off a considerable pro-
portion of the portal blood.
Symptoms. — The most extreme grade of atrophic cirrhosis may exist with-
out s}^nptoms. So long as the compensatory circulation is maintained the
patient may suffer little or no inconvenience. The remarkable efficiency of
this collateral circulation is well seen in those rare instances of permanent
obliteration of the portal vein. The s}Tnptoms may be divided into two groups
— obstructive and toxic.
Obstructive. — The overfilling of the blood-vessels of the stomach and
intestine lead to chronic catarrh, and the patients suffer with nausea and vom-
iting, particularly in the morning; the tongue is furred and the bowels are
irregular. Haemorrhage from the stomach may be an early symptom; it is
often profuse and liable to recur. It seldom proves fatal. The amount vom-
ited may be remarkable, as in a case already referred to, in which ten pounds
were ejected in seven days. Following the haematemesis melsena is common;
DISEASES OF THE LIVER. 559
but hsemorrhages from the bowels may occur for several years without hgema-
temesis. The bleeding very often comes from the oesophageal varices already
described (p. 459). Very frequently epistaxis occurs. Enlargement of the
spleen may, as Parkes Weber suggests, be due to a toxemia. The organ can
usually be felt. Evidences of the establishment of the collateral circulation
are seen in the enlarged epigastric and mammary veins, more rarely in the
presence of the caput Medusae and in the development of haemorrhoids. ■ The
distended venules in the lower thoracic zone along the line of attachment
of the diaphragm are not specially marked in cirrhosis. The most striking
feature of failure in the compensatory circulation is ascites, the effusion of
serous fluid into the peritoneal cavity, which may appear suddenly. The
conditions under which this occurs are still obscure. In some cases it is
due more to chronic peritonitis than to the cirrhosis. The abdomen gradu-
ally distends, may reach a large size, and contain as much as 15 or 20 litres.
QEdema of the feet may precede or develop with the ascites. The dropsy is
rarely general.
Jaundice is usually slight, and was present in 107 of ^^ cases^of_£irrhosis
collected by JRolleston. The skin has frequently a sallow, slightly icteroid
tint. The urine is often reduced in amount, contains urates in abundance,
often a slight amount of albumin, and, if jaundice is intense, tube-casts. The
disease may be afebrile throughout, but in many cases, as shown by Carring-
ton, there is slight fever, from 100° to 102.5°.
Examination at any early stage of the disease may show an enlarged and
painful liver. Dreschfeld, Foxwell, and Eolleston have of late years called
particular attention to the fact that in very many of the. cases of alcoholic cir-
rhosis the organ is " enlarged at all stages of the disease, and that whether
enlarged or contracted the clinical symptoms and course are much the same "
(Foxwell). The patient may first come under observation for dyspepsia,
hsematemesis, slight jaundice, or nervous symptoms. Later in the disease,
the patient has an unmistakable hepatic f acies ; he is thin, the eyes are sunken,
the conjunctivae watery, the nose and cheeks show distended venules, and the
complexion is muddy or icteroid. On the enlarged abdomen the vessels are
distended, and a bunch of dilated veins may surround the navel. Naevi of a
remarkable character may appear on the skin, either localized stellate varices —
spider angiomata — usually on the face, neck, and back, and also " mat " naevi,
as I have called them — areas of skin of a reddish or purplish color due to the
uniform distention of small venules. "When much fluid is in the peritonaeum
it is impossible to make a satisfactory examination, but after withdrawal the
area of liver dulness is found to be diminished, particularly in the middle
line, and on deep pressure the edge of the liver can be detected, and occa-
sionally the hard, firm, and even granular surface. The spleen can be felt
in the left hypochondriac region. Examination of the anus may reveal the
presence of hremorrhoids.
Toxic Symptoms. — At any stage of atrophic cirrhosis the patient may
have cerebral symptoms, either a noisy, joyous delirium, or stupor, coma, or
even convulsions. The condition is not infrequently mistaken for uraemia.
The nature of the toxic agent is not yet settled. Without jaundice, and not
attributable to cholaemia, the symptoms may come on in hospital when the
patient has not had alcohol for weeks.
560 DISEASES OF THE DIGESTIVE SYSTEM.
The fatty cirrhotic liver may produce symptoms similar to those of the
atrophic form^ but more frequently it is latent and is found accidentally in
topers who have died from various diseases. The greater number of the cases
clinically diagnosed as cirrhosis with enlargement come in this division.
Diagnosis. — With ascites, a well-marked history of alcoholism, the hepatic
facies, and hsemorrhage from the stomach or bowels, the diagnosis is rarely
doubtful. If, after withdrawal of the fluid, the spleen is found to be en-
larged and the liver either not palpable or, if it is enlarged, hard and regu-
lar, the probabilities in favor of cirrhosis are very great. In the early stages
of the disease, when the liver is increased in size, it may be impossible to say
whether it is a cirrhotic or a fatty liver. The differential diagnosis between
common and syphilitic cirrhosis can sometimes be made. A marked history
of syphilis or the existence of other syphilitic lesions, with great irregularity
in the surface or at the edge of the liver, are the points in favor of the latter.
Thrombosis or obliteration of the portal vein can rarely be differentiated. In
a case of fibroid transformation of the portal vein which came under my
observation, the collateral circulation had been established for years, and the
symptoms were simply those of extreme portal obstruction, such as occur in
cirrhosis. Thrombosis of the portal vein may occur in cirrhosis and be char-
acterized by a rapidly developing ascites.
Prognosis. — The prognosis is bad. When the collateral circulation is fully
established the patient may have no symptoms whatever. Three cases of
advanced atrophic cirrhosis have died under my observation of other affec-
tions without presenting during life any symptoms pointing to disease of the
liver. There are instances, too, of enlargement of the liver, slight jaundice,
cerebral symptoms, and even hgematemesis, in which the liver becomes reduced
in size, the symptoms disappear, and the patient may live in comparative com-
fort for many years. There are cases, too, possibly syphilitic, in which, after
one or two tappings, the symptoms have disappeared and the patients have
apparently recovered. Ascites is a very serious event, especially if due to the
cirrhosis and not to an associated peritonitis. Of 34 cases with ascites 10 died
before tapping was necessary; 14 were tapped, and the average duration of
life after the swelling was first noticed was only eight weeks; of 10 cases the
diagnosis was wrong in 4, and in the remaining 6, who were tapped oftener
than once, chronic peritonitis and perihepatitis were present (Hale White).
II. Hypertrophic Cirrhosis {Hanoi).
This well-characterized form was first described by Eequin in 1846, but
our accurate knowledge of the condition dates from the work of the lamented
Hanot (1875), whose name in France it bears — maladie de Hanoi.
Cirrhosis with enlargement occurs in the early stage of atrophic cirrhosis;
there is an enlarged fatty and cirrhotic liver of alcoholics, a pigmentary form
in diabetes has been described, and in association with syphilis the organ is
often very large. The h3rpertrophic cirrhosis of Hanot is easily distinguished
from these forms.
Etiology. — Males are more often affected than females — in 22 of Schach-
mann's 26 cases. The subjects are young; some of the cases in children prob-
ably belong to this form. Of four recent cases under my care the ages were
DISEASES OF THE LIVER. 561
from twenty to thirty-five. Two were brotliers. Alcohol plays a minor part.
Not one of the four cases referred to had been a heavy drinker. The absence
of all known etiological factors is a remarkable feature in a majority of the
cases.
Morbid Anatomy. — The organ is enlarged, weighing from 2,000 to 4,000
grammes. The form is maintained, the surface is smooth, or presents small
granulations ; the color in advanced cases is of a dark olive green ; the con-
sistence is greatly increased. The section is uniform, greenish-yellow in color,
and the liver nodules may be seen separated by connective tissue. The bile-
passages present nothing abnormal. In a case without much jaundice ex-
ploratory operation showed a very large red organ, with a slightly roughened
surface. Microscopically the following characteristics are described by French
writers : The cirrhosis is mono- or multilobular, with a connective tissue rich
in round cells. The bile-vessels are the seat of an angiocholitis, catarrhal and
productive, and there is an extraordinary development of new biliary canaliculi.
The liver-cells are neither fatty nor pigmented, and may be increased in size
and show karyokinetic figures. From the supposed origin about the bile-
vessels it has been called biliary cirrhosis, but the histological details have not
yet been worked out fully, and the separation of this as a distinct form should,
for the present at least, rest upon clinical rather than anatomical grounds.
The spleen is greatly enlarged and may weigh 600 or more grammes.
Symptoms. — Hanot's hypertrophic cirrhosis presents the following very
characteristic group of symptoms. As previously stated, the cases occur in
young persons; there is not, as a rule, an alcoholic history, and males are
usually affected: (a) A remarkably chronic course of from four to six, or
even ten years, (h) Jaundice, usually slight, often not more than, a lemon
tint^or a tingingjpf the cpnjunctiyge. At any time during the course an icterus^
gravis, with high fever and delirium, may develop. There is bile in the urine ;
the stools are not clay-colored as in obstructive jaundice, but may be very
dark and "bilious." (c) Attacks of pain in the region of the liver, which
may be severe and associated with nausea and vomiting. The pain may be
slight and dragging, and in some cases is not at all a prominent symptom.
The jaundice may deepen after attacks of pain, (d) Enlarged liver. A ful-
ness in the upper abdominal zone may be the first complaint. On inspection
the enlargement may be very marked. In one of my cases the left lobe was
unusually prominent and stood out almost like a tumor. An exploratory oper-
ation showed only an enlarged, smooth organ without adhesions. On palpa-
tion the hypertrophy is uniform, the consistence is increased, and the edge
distinct and hard. The gall-bladder is not enlarged. The vertical flatness is
much increased and may extend from the sixth rib to the level of the navel,
(e) The spleen is enlarged, easily palpable, and very hard. (/) Certain nega-
tive features are of moment — the usual absence of ascites and of dilatation
of the subcutaneous veins of the abdomen. Among other symptoms may be
mentioned haemorrhages. One of my cases had bleeding at the gums for a
year; another had had for years most remarkable attacks of purpura with
urticaria. Pruritus, xanthoma, lichen, and telangiectasis may be present in
the skin. In one of my cases the skin became very bronzed, almost as deeply
as in Addison's disease. Slight fever may be present, which increases during
the crises of pain. There may be a marked leucocytosis. A curious attitude
37
562 DISEASES OF THE DIGESTIVE SYSTEM.
of the body lias l)een seen, in which the right shoulder and right side look
dragged down. The patients die with the symptoms of icterus gravis, from
haemorrhage, from an intercurrent infection, or in a profound cachexia. Cer-
tain of the cases of cirrhosis of the liver in children are of this type; the
enlargement of the spleen may be very pronounced.
III. Syphilitic Cirrhosis.
This has already been considered in the section on syphilis (p. 275). I
refer to it again to emphasize (1) its frequency; (2) the great importance of
its differentiation from the alcoholic form; (3) its curability in many cases;
and (4) the tumor formations in connection with it.
IV. Capsular Cirrhosis — Perihepatitis.
Local capsulitis is common in many conditions of the liver. The form
of disease here described is characterized by an enormous thickening of the
entire capsule, with great contraction of the liver, but not necessarily with spe-
cial increase in the connective tissue of the organ itself. Our chief knowledge
of the disease we owe to the Guy's Hospital physicians, particularly to Hilton
Fagge and to Hale White, who has collected from the records 22 cases. The
liver substance itself was " never markedly cirrhotic ; its tissue was nearly
always soft." Chronic capsulitis of the spleen and a chronic proliferative peri-
tonitis are almost invariably present. In 19 of the 22 cases the kidneys were
granular. Hale White regards it as a sequel of interstitial nephritis. The
youngest case in his series was twenty-nine. The symptoms are those of
atrophic cirrhosis — ascites, often recurring and requiring many tappings.
Jaundice is not often present. I have met with two groups of cases — the one
in adults usually with ascites and regarded as ordinary cirrhosis. I have
never made a diagnosis in such a case. Signs of interstitial nephritis, recur-
ring ascites, and absence of jaundice are regarded by Hale White as im-
portant diagnostic points. In the second group of cases the perihepatitis,
perisplenitis, and proliferative peritonitis are associated with adherent pericar-
dium and chronic mediastinitis. In one such case the diagnosis of capsular
hepatitis was very clear, as the liver could be grasped in the hand and formed
a rounded, smooth organ resembling the spleen. The child was tapped 121
times (Archives of Paediatrics, 1896).
Treatment of the Cirrhoses. — The portal function of the liver may be put
out of action without much damage to the body. There may be an extreme
grade of cirrhotic atrophy without symptoms; the portal vein may be obliter-
ated, or, experimentally the portal vein may be anastomosed with the cava.
So long as there is an active compensatory circulation a patient with atrophic
cirrhosis may remain well. In the hypertrophic form toxaemia is the special
danger. In the hypertrophic cirrhosis we have no means of arresting the prog-
ress of the disease. In the alcoholic form it is too late, as a rule, to do much
after symptoms have occurred. In a few cases an attack of jaundice or
hffimatemesis may prove the salvation of the patient, who may afterward take
to a temperate life and a bland diet. An occasional course of potassium iodide
may be given. With the advent of ascites the critical stage is reached. A dry
diet, without salt, and free purgation may relieve a small exudate, rarely a
DISEASES OF THE LIVER. 563
large one, and it is best to tap early, or to advise Talma's operation. In the
syphilitic cirrhosis much more can be done, and a majority of the cases of cure
after ascites are of this variety. Iodide of potassium in moderate doses, 15
to 30 drops of the saturated solution, and the Addison pill save a number of
cases even after repeated tapping. The diagnosis may be reached only after
removal of the fluid, but in every case with a history of syphilis or with irreg-
ularity of the liver this treatment should be tried.
Surgical Treatment. — (a) Tapping. — When the ascites increases it is
better to tap early. As Hale White remarks, a case of cirrhosis of the liver
which is tapped rarely recovers, but there are instances in which early and
repeated paracentesis is followed by cure. Accidents are rare; hemorrhage
occasionally follows ; acute peritonitis ; erysipelas at the point of puncture ; col-
lapse during the operation, to guard against which Mead advised the use of the
abdominal binder. Continuous drainage with Southey's tubes is not often
practicable and has no special advantages, (&) Laparotomy, with complete
removal of the fluid, and freshening or rubbing the peritoneal surfaces, to
stimulate the formation of adhesions, (c) Omentopexy, the stitching of the
omentum to the abdominal wall, and the establishment of collateral circula-
tion in this way between the portal and the systemic vessels. This operation
is sometimes very successful, and may be recommended. In 324 cases there
were 84 deaths and 129 recoveries; 11 cases doubtful. Among the 129 suc-
cessful cases, in 25 the ascites recurred ; 70 appeared to have completely recov-
ered, (d) Fistula of Ech. The porto-caval anastomosis has been performed
once in man in cirrhosis of the liver by Widal {La Semaine Medicale, 1903).
The jDatient lived for three months.
VIII. ABSCESS OF THE LIVER.
Etiology. — Suppuration within the liver, either in the parenchyma or in
the blood or bile passages, occurs under the following conditions :
(1) The tropical abscess, also called the solitary, commonly follows amoebic
dysentery. It frequently occurs among Europeans in India, particularly those
who drink alcohol freely and are exposed to great heat. The relation of this
form of abscess to dysentery is still under discussion, and Anglo-Indian prac-
titioners are by no means unanimous on the subject. Certainly cases may
occur without a history of previous dysentery, and there have been fatal cases
without any affection of the large bowel. In the United States the large soli-
tary abscess is not very infrequent. The relation of this form of abscess to
the Amceba dysenterice has been considered.
(2) Traumatism is an occasional cause. The injury is generally in the
hepatic region. Two instances of it have come under my notice in brakemen
who were injured while coupling cars. Injury to the head is not infrequently
followed by liver abscess.
(3) Embolic or pycemic abscesses are the most numerous, occurring in a
general pyaemia or following foci of suppuration in the territory of the portal
vessels. The infective agents may reach the liver through the hepatic artery,
as in those cases in which the original focus of infection is in the area of the
systemic circulation; though it may happen occasionally that the infective
agent, instead of passing through the lungs, reaches the liver through the infe-
564 DISEASES OF THE DIGESTIVE SYSTEM.
rior vena cava and the hepatic veins. A remarkable instance of multiple
abscesses of arterial origin was afforded by the case of aneurism of the hepatic
artery reported by Eoss and myself. Infection through the portal vein is
much more common. It results from dysentery and other ulcerative affections
of the bowels, appendicitis, occasionally after typhoid fever, in rectal affec-
tions, and in abscesses in the pelvis. In these cases the abscesses are multiple
and, as a rule, within the branches of the portal vein — suppurative pylephle-
bitis.
(4) A not uncommon cause of suppuration is inflammation of tJie tile-
passages caused by gall-stones, more rarely by parasites — suppurative cho-
langitis.
In some instances of tuberculosis of the liver the affection is chiefly of
the bile-ducts, with the formation of multiple tuberculous abscesses containing
a bile-stained pus.
(5) Foreign todies and parasites. In rare instances foreign bodies, such
as a needle, may pass from the stomach or gullet, lodge in the liver, and
excite an abscess, or, as in several instances which have been reported, a for-
eign body, such as a needle or a fish-bone, has perforated a branch or the por-
tal vein itself and induced pylephlebitis. Echinococcus cysts frequently cause
suppuration, the penetration of round worms into the liver less commonly,
and most rarely of all the liver-fluke.
Morbid Anatomy. — (a) Of the Solitary or Tropical Abscess. — This
has been described under amoebic dysentery (p. 4).
(6) Oe Septic and Pyemic Abscesses. — These are usually multiple,
though occasionally, following injury, there may be a large solitary collection
of pus.
In suppurative pylephlebitis the liver is uniformly enlarged. The cap-
sule may be smooth and the external surface of the organ of normal appearance.
In other instances, numerous yellowish-white points appear beneath the cap-
sule. On section there are isolated pockets of pus, either having a round out-
line or in some places distinctly dendritic, and from these the pus may be
squeezed. They look like small, solitary abscesses, but, on probing, are found
to communicate with the portal vein and to represent its branches, distended
and suppurating. The entire portal system vsdthin the liver may be involved ;
sometimes territories are cut off by thrombi. The suppuration may extend into
the main branch or even into the mesenteric and gastric veins. The pus may
be fetid and is often bile-stained; it may, however, be thick, tenacious, and
laudable. In suppurative cholangitis there is usually obstruction by gall-
stones, the ducts are greatly distended, the gall-bladder enlarged and full of
pus, and the branches within the liver are extremely distended, so that on
section there is an appearance not unlike that described in pylephlebitis.
Suppuration about the echinococcus cysts may be very extensive, forming
enormous abscesses, the characters of which are at once recognized by the rem-
nants of the cysts.
Symptoms. — {a) Oe the Large Solitary Abscess. — The abscess may be
latent and run a course without definite s5miptoms; death may occur sud-
denly from rupture.
Fever, pain, enlargement of the liver, and a septic condition are the impor-
tant symptoms of hepatic abscess. The temperature is elevated at the outset
DISEASES OF THE LIVER. 565
and is of an intermittent or septic type. It is irregular, and may remain
normal or even subnormal for a few days; then the patient has a rigor and
the temperature rises to 103° or higher. Owing to this intermittent character
of the fever the disease is often mistaken for malaria. The fever may rise
every afternoon without a rigor. Profuse sweating is common, particularly
when the patient falls asleep. In chronic cases there may be little or no
fever. One of my patients, with a liver abscess which had perforated the lung,
coughed up pus after his temperature had been normal for weeks. The pain
is variable, and is usually referred to the back or shoulder; or there is a dull
aching sensation in the right hypochondrium. When turned on the left side,
the patient often complains of a heavy, dragging sensation, so that he usually
prefers to lie on the right side ; at least, this has been the case in a majority of
the instances which have come under my observation. Pain on pressure over
the liver is usually present, particularly on deep pressure at the costal margin
in the nipple line.
The enlargement of the liver is most marked in the right lobe, and, as
the abscess cavity is usually situated more toward the upper than the under
.surface, the increase in volume is upward and to the right, not downward, as
in cancer and the other affections producing enlargement. Percussion in the
mid-sternal and parasternal lines may show a normal limit. At the nipple-
line the curve of liver dulness begins to rise, and in the mid-axillary it may
reach the fifth rib, while behind, near the spine, the area of dulness may be
almost on a level with the angle of the scapula. Of course there are instances
in which this characteristic feature is not present, as when the abscess occu-
pies the left lobe. The enlargement of the liver may be so great as to cause
bulging of the right side, and the edge may project a hand's-breadth or more
below the costal margin. In such instances the surface is smooth. Palpation
is painful, and there may be fremitus on deep inspiration. In some instances
fluctuation may be detected. Adhesions may form to the abdominal wall and
the abscess may point below the margin of the ribs, or even in the epigastric
region. In many cases the appearance of the patient is suggestive. The skin
has a sallow, slightly icteroid tint, the face is pale, the complexion muddy, the
conjunctivae are infiltrated, and often slightly bile-tinged. There is in the
facies and in the general appearance of the patient a strong suggestion of the
existence of abscess. There is no internal affection associated with suppura-
tion which gives, I think, just the same hue as certain instances of abscess of
the liver. Marked jaundice is rare. Diarrhoea may be present and may give
an important clew to the nature of the case, particularly if amoebae are found
in the stools. Constipation may occur.
Perforation of the lung occurred in 9 of the 27 cases in my series. The
symptoms are most characteristic. The extension may occur through the dia-
phragm, without actual rupture, and^ with the production of a purulent pleu-
risy and invasion of the lung. With cough of an aggravated and convulsive
character, there are signs of involvement at the base of the right lung, defective
resonance, feeble tubular breathing, and increase in the tactile fremitus; but
the most characteristic feature is the presence of a reddish-brown expectoration
of a brick-dust color, resembling anchovy sauce. This, which was noted origi-
nally by Budd, was present in our cases, and in addition Eeese and Lafleur
found the amcebce coli identical with those which exist in the liver abscess and
566 DISEASES OF THE DIGESTIVE SYSTEM.
in the stools. They are present in variable numbers and display active amoe-
boid movements. The brownish tint of the exj)ectoration is due to blood-
pigment and blood-corpuscles^ and there may be orange-red crystals of h^ma-
toidin.
The abscess may perforate externally, as mentioned already, or into the
stomach or bowel; occasionally into the pericardium. The duration of this
form is very variable. It may run its course and prove fatal in six or eight
weeks or may persist for several years.
The prognosis is serious, as the mortality is more than 50 per cent. The
death-rate has been lowered of late years, owing to the great fearlessness with
which the surgeons now attack these cases.
(b) Of the Pyemic Abscess and Suppurative Pylephlebitis. — Clin-
ically these conditions can not be separated. Occurring in a general pygemia,
no special features may be added to the case. When there is suppuration
within the portal vein the liver is uniformly enlarged and tender, though
pain may not be a marked feature. There is an irregular, septic fever, and
the complexion is muddy, sometimes distinctly icteroid. The features are
indeed those of pyaemia, plus a slight icteroid tinge, and an enlarged and
painful liver. The latter features alone are peculiar. The sweats, chills, pros-
tration, and fever have nothing distinctive.
Diagnosis. — Abscess of the liver may be confounded with intermittent
fever, a common mistake in malarial regions. Practically an intermittent
fever which resists quinine is not malarial. Laveran's organisms are also
absent from the blood. When the abscess bursts into the pleura a right-sided
empyema is produced and perforation of the lung usually follows. When
the liver abscess has been latent and dysenteric symptoms have not been
marked, the condition may be considered empyema or abscess of the lung.
In such cases the anchovy-sauce-like color of the pus and the presence of
the amoeba will enable one to make a definite diagnosis. Perforation exter-
nally is readily recognized, and yet in an abscess cavity in the epigastric region
it may be difficult to say whether it has proceeded from the liver or is in the
abdominal wall. When the abscess is large, and the adhesions are so firm
that the liver does not descend during inspiration, the exploratory needle does
not make an up-and-down movement during aspiration. The diagnosis of
suppurating echinococcus cyst is rarely possible, except in Australia and Ice-
land, where hydatids are so common.
Perhaps the most important affection from which suppuration within the
liver is to be separated is the intermittent hepatic fever associated with gall-
stones. Of the cases reported a majority have been considered due to suppu-
ration, and in two of my cases the liver had been repeatedly aspirated. Post-
mortem examinations have shown conclusively that the high fever and chills
may recur at intervals for years without suppuration in the ducts. The dis-
tinctive features of this condition are paroxysms of fever with rigors and
sweats — which may occur with great regularity, but which more often are
separated by long intervals — the deepening of the jaundice after the parox-
ysms, the entire apyrexia in the intervals, and the maintenance of the general
nutrition. The time element also is important, as in some of these cases the
disease has lasted for several years. Finally, it is to be remembered that
abscess of the liver, in temperate climates at least, is invariably secondary, and
DISEASES OF THE LIVER. 567
the primary source must be carefully sought for, either in dysentery, slight
ulceration of the rectum, suppurating haemorrhoids, ulcer of the stomach, or
in suppurative disease of other parts of the body, particularly within the skull
or in the bones.
Leucocytosis may be absent in the amoebic abscess of the liver; in septic
cases it may be very high.
In suspected cases, whether the liver is enlarged or not, exploratory aspira-
tion may be performed without risk. The needle may be entered in the ante-
rior axillary line in the lowest interspace, or in the seventh interspace in the
mid-axillary line, or over the centre of the area of dulness behind. The patient
should be placed under ether, for it may be necessary to make several deep
punctures. It is not well to use too small an aspirator. No ill effects follow
this procedure, even though blood may leak into the peritoneal cavity. Ex-
tensive suppuration may exist, and yet be missed in the aspiration, particu-
larly when the branches of the portal vein are distended with pus.
Treatment. — Pysemic abscess and suppurative pylephlebitis are invariably
fatal. Treves, however, reports a case of pyaemic abscess following appendi-
citis in which the patient recovered after an exploratory operation. Surgical
measures are not justified in these cases, unless an abscess shows signs of
pointing. As the abscesses associated with dysentery are often single, they
afford a reasonable hope of benefit from operation. If, however, the patient
is expectorating the pus, if the general condition is good and the hectic fever
not marked, it is best to defer operation, as many of these instances recover
spontaneously. The large single abscesses are the most favorable for operation.
The general medical treatment of the cases is that of ordinary septicsemia.
IX. NEW GROWTHS IN THE LIVER.
These may be cancer, either primary or secondary, sarcoma, or angioma.
Etiology. — Cancer of the liver is third in order of frequency of internal
cancer. It is rarely primary, usually secondary to cancer in other organs.
It is a disease of late adult life. According to Leichtenstern, over 50 per cent
of the cases occur between the fortieth and the sixtieth years. It occasionally
occurs in children. Women are attacked less frequently than men. It is
stated by some authors that secondary cancer is more common in women, owing
to the frequency of cancer of the uterus. Heredity is believed to have an influ-
ence in from 15 to 20 per cent.
In many cases trauma is an antecedent, and cancer of the bile-passages is
associated in many instances with gall-stones. Cancer is stated to be less
common in the tropics.
Morbid Anatomy. — The following forms of new growths occur in the liver
and have a clinical importance :
Cancek. — (1) Primary cancer, of which three forms may be recognized.
(a) The massive cancer, which causes great enlargement and on section
shows a uniform mass of new growth, which occupies a large portion of the
organ. It is grayish-white, usually not softened, and is abruptly outlined
from the contiguous liver substance.
(&) Nodular cancer, in which the liver is occupied by nodular masses,
some large, some small, irregularly scattered throughout the organ. Usu-
568 DISEASES OF THE DIGESTIVE SYSTEM.
ally in one region there is a larger, perhaps firmer, older-looking mass, which
indicates the primary seat, and the numerous nodules are secondary to it.
This form is much like the secondary cancerous involvement, except that it
seldom reaches a large size.
(c) Adeno-carcinoma with cirrhosis. The liver varies in size, small as
a rule, but in a few cases enlarged. The surface is usually mottled dark green,
with elevated yellowish nodules beneath the capsule, or even large globular
masses projecting. On section the tissue is bile-stained, and there are innu-
merable tumor masses, varying in size, separated from each other by strands
of connective tissue, which may be 5 to 10 mm. across. The growths may be
unevenly distributed. The connection between the adenoma and the cirrhosis
is not known, nor is it known which is primary. There is, as a rule, extensive
vicarious hypertrophy of the liver tissue. Of the two cases which have been
under my care, in one I diagnosed cirrhosis, and the clinical picture was that
of the ordinary atrophic form; the other I thought to be carcinoma (C. H.
Travis, J. H. H. Bull., 1902). The latter patient died of haemorrhage into
the peritoneal cavity, a similar ending to that in the case reported by Peabody.
Histologically, the primary cancers are epitheliomata — alveolar and trabec-
ular. The character of the cells varies greatly. In some varieties they are poly-
morphous ; in others small polyhedral ; in others, again, giant cells are found.
In rare instances, as in one described by Greenfield, the cells are cylindrical.
The trabecular form of epithelioma is also known as adenoma or adeno-
carcinoma.
(2) Secondary Cancer. — The organ may reach an enormous size, 30^
pounds (Osier), 33 pounds (Christian). The cancerous nodules project
beneath the capsule, and can be felt during life or even seen through the
thin abdominal walls. They are usually disseminated equally, though in rare
instances they may be confined to one lobe. The consistence of the nodules
varies; in some cases they are firm and hard and those on the surface show
a distinct umbilication, due to the shrinking of the fibrous tissue in the centre.
These superficial cancerous masses are still sometimes spoken of as " Farre's
tubercles." More frequently the masses are on section grayish-white in color,
or hsemorrhagic. Eupture of blood-vessels is not uncommon in these cases.
In one specimen there was an enormous clot beneath the capsule of the liver,
together with haemorrhage into the gall-bladder and into the peritonaeum.
The secondary cancer shows the same structure as the initial lesion, and is
usually either an alveolar or cylindrical carcinoma. Degeneration is common
in these secondary growths ; thus the hyaline transformation may convert large
areas into a dense, dry, grayish-yellow mass. Extensive areas of fatty degen-
eration may occur, sclerosis is not uncommon, and haemorrhages are frequent.
Suppuration sometimes follows.
(3) Cancer of the hile-passages which has been already considered.
Sarcoma. — Of primary sarcoma of the liver very few cases have been re-
ported. Secondary sarcoma is more frequent, and many examples of lympho-
sarcoma and myxo-sarcoma are on record, less frequently glio-sarcoma or the
smooth or striped myoma.
The most important form is the melano-sarcoma, secondary to sarcoma
of the eye or of the skin. Very rarely melano-sarcoma occurs primarily in the
liver. Of the reported cases Hanot excludes all but one. In this form the
DISEASES OF THE LIVER. 569
liver is greatly enlarged, is either uniformly infiltrated with the growth which
gives the cut surface the appearance of dark granite, or there are large nodu-
lar masses of a deep black or marbled color. There are usually extensive metas-
tases, and in some instances every organ of the body is involved. Nodules of
melano-sarcoma of the skin may give a clew to the diagnosis.
Other Forms of Liver Tumor. — One of the commonest tumors in the
liver is the angioma, which occurs as a small, reddish body the size of a
walnut, and consists simply of a series of dilated vessels. Occasionally in chil-
dren angiomata grow and produce large tumors.
Cysts are occasionally found in the liver, either single, which is not very
uncommon, or multiple, when they usually coexist with congenital cystic
kidneys.
Symptoms. — It is often impossible to differentiate primary and secondary
cancer of the liver unless the primary seat of the disease is evident, as in the
case of scirrhus of the breast, or cancer of the rectum, or of a tumor in the
stomach, which can be felt. As a rule, cancer of the liver is associated with
progressive enlargement; but in some cases of primary nodular cancer, and
in the cancer with cirrhosis the organ may not be enlarged. Gastric disturb-
ance, loss of appetite, nausea, and vomiting are frequent. Progressive loss of
flesh and strength may be the first symptoms. Pain or a sensation of uneasi-
ness in the right hypochondriac region may be present, but enormous enlarge-
ment of the liver may occur without the slightest pain. Jaundice, which is
present in at least one-half of the cases, is usually of moderate extent, unless
the common duct is occluded. Ascites is rare, except in the form of cancer
with cirrhosis, in which the clinical picture is that of the atrophic form. Pres-
sure by nodules on the portal vein or extension of the cancer to the peritonaeum
may also induce ascites.
Inspection shows the abdomen to be distended, particularly in the upper
zone. In late stages of the disease, when emaciation is marked, the cancerous
nodules can be plainly seen beneath the skin, and in rare instances even the
umbilications. The superficial veins are enlarged. On palpation the liver is
felt, a hand's-breadth or more below the costal margin, descending with each
inspiration. The surface is usually irregular, and may present large masses
or smaller nodular bodies, either rounded or with central depressions. In
instances of diffuse infiltration the liver may be greatly enlarged and present
a perfectly smooth surface. The growth is progressive, and the edge of the
liver may ultimately extend below the level of the navel. Although generally
uniform and producing enlargement of the whole organ, occasionally the
tumor in the left lobe forms a solid mass occupying the epigastric region. By
percussion the outline can be accurately limited and the progressive growth of
the tumor estimated. The spleen is rarely enlarged. Pyrexia is present in
many cases, usually a continuous fever, ranging from 100° to 102° ; it may be
intermittent, with rigors. This may be associated with the cancer alone, or,
as in one of my cases, with suppuration. (Edema of the feet, from anaemia,
usually Supervenes. Cancer of the liver kills in from three to fifteen months.
One of my patients lived for more than two years.
Diagnosis. — The diagnosis is easy when the liver is greatly enlarged and
the surface nodular. The smoother forms of diffuse carcinoma may at first
be mistaken for fatty or amyloid liver, but the presence of jaundice, the rapid
38
570 DISEASES OP THE DIGESTIVE SYSTEM.
enlargement, and the more marked cachexia will usually suffice to differen-
tiate it. Perhaps the most puzzling conditions occur in the rare cases of
enlarged amyloid liver with irregular gummata. The large echinococcus liver
may present a striking similarity to carcinoma, but the projecting nodules
are usually softer, the disease lasts much longer, and the cachexia is not
marked.
Hypertrophic cirrhosis may at first be mistaken for carcinoma, as the jaun-
dice is usually deep and the liver very large; but the absence of a marked
cachexia and wasting, and the painless, smooth character of the enlargement
are points against cancer. When in doubt in these cases, aspiration may be
safely performed, and positive indication may be gained from the materials
so obtained. In large, rapidly growing secondary cancers the superficial
rounded masses may almost fluctuate and these soft tumor-like projections may
contain blood. The form of cancer with cirrhosis can scarcely be separated
from atrophic cirrhosis itself. Perhaps the wasting is more extreme and more
rapid, but the jaundice and the ascites are identical. Melano-sarcoma causes,
great enlargement of the organ. There are frequently symptoms of involve-
ment of other viscera, as the lungs, kidneys, or spleen. Secondary tumors
may occur in the skin. A very important symptom, not present in all cases,
is melanuria, the passage of a very dark-colored urine, which may, however,
when first voided, be quite normal in color. The existence of a melano-sar-
coma of the eye, or the history of blindness in one eye, with subsequent extir-
pation, may indicate at once the true nature of the hepatic enlargement. The
secondary tumors may arise some time after the extirpation of the eye, as in
a case under the care of J. C. Wilson, at the Philadelphia Hospital, or, as in
a case under Tyson at the same institution, the patient may have a sarcoma
of the choroid which had never caused any symptoms.
The treatment must be entirely symptomatic. The question of surgical
interference may be discussed. Keen has collected reports of 76 cases of resec-
tion of tumors of the liver, 63 of which recovered.
X. FATTY LIVER.
Two different forms of this condition are recognized — ^the fatty infiltra-
tion and fatty degeneration.
Fatty infiltration occurs, to a certain extent, in normal livers, since the cells
always contain minute globules of oil.
In fatty degeneration, which is a much less common condition, the proto-
plasm of the liver-cells is destroyed and the fat takes its place, as seen in cases
of malignant jaundice and in phosphorus poisoning.
Fatty liver occurs under the following conditions: (a) In association with
general obesity, in which case the liver appears to be one of the storehouses of
the excessive fat. (h) In conditions in which the oxidation processes are inter-
fered with, as in cachexia, profound angemia, and in phthisis. The fatty infil-
tration of the liver in heavy drinkers is to be attributed to the excessive demand
made by the alcohol upon the oxygen, (c) Certain poisons, of which phos-
phorus is the most characteristic, produce an intense fatty degeneration with
necrosis of the liver-cells. The poison of acute yellow atrophy, whatever its
nature, acts in the same way.
DISEASES OF THE LIVER. 571
The fatty liver is uniformly increased in size. The edge may reach below
the level of the navel. It is smooth, looks pale and bloodless ; on section it is
dry, and renders the surface of the knife greasy. The liver may weigh many
pounds, and yet the specific gravity is so low that the entire organ floats in
water.
The symptoms of fatty liver are not definite. Jaundice is never present;
the stools may be light-colored, but even in the most advanced grades the bile
is still formed. Signs of portal obstruction are rare. Hsemorrhoids are not
very infrequent. Altogether, the symptoms are ill-defined, and are chiefly those
of the disease with which the degeneration is associated. In cases of great
obesity, the physical examination is uncertain; but in phthisis and cachectic
conditions, the organ can be felt to be greatly enlarged, though smooth and
painless. Fatty livers are among the largest met with at the bedside,
XI. AMYLOID LIVER.
The waxy, lardaceous, or amyloid liver occurs as part of a general degen-
eration, associated with cachexias, particularly when the result of long-stand-
ing suppuration.
In practice, it is found oftenest in the prolonged suppuration of tubercu-
lous disease, either of the lungs or of the bones. Next in order of frequency
are the cases associated with syphilis. Here there may be ulceration of the
rectum, with which it is often connected, or chronic disease of the bone, or it
may be present when there are no suppurative changes. It is found occasion-
ally in rickets, in prolonged convalescence from the infectious fevers, and in
the cachexia of cancer.
The amyloid liver is large, and may attain dimensions equalled only by
those of the cancerous organ. Wilks speaks of a liver weighing fourteen
pounds. It is solid, flrm, resistant, on section anaemic, and has a semitranslu-
cent, infiltrated appearance. Stained with a dilute solution of iodine, the
areas infiltrated with the amyloid matter assume a rich mahogany-brown color.
The precise nature of this change is still in question. It first attacks the
capillaries, usually of the median zone of the lobules, and subsequently the
interlobular vessels and the connective tissue. The cells are but little if at
all affected.
There are no characteristic symptoms of this condition. Jaundice does not
occur ; the stools may be light-colored, but the secretion of bile persists. The
physical examination shows the organ to be uniformly enlarged and painless,
the surface smooth, the edge rounded, and the consistence greatly increased.
Sometimes the edge, even in very great enlargement, is sharp and hard. The
spleen also may be involved, but there are no evidences of portal obstruction.
The diagnosis of the condition is, as a rule, easy. Progressive and great
enlargement in connection with suppuration of long standing or with syphilis,
is almost always of this nature. In rare instances, however, the amyloid liver
is reduced in size.
In leukcemia the liver may attain considerable size and be smooth and uni-
form, resembling, on physical examination, the fatty organ. The blood condi-
tion at once indicates the true nature of the case.
572 DISEASES OF THE DIGESTIVE SYSTEM.
XII. ANOMALIES IN FORM AND POSITION OF THE
LIVER.
In transposition of the viscera the right lobe of the organ may occupy the
left side. A common and important anomaly is the tilting forward of the
organ, so that the antero-posterior axis becomes vertical, not horizontal. In-
stead of the edge of the right lobe presenting just below the costal margin, a
considerable portion of the surface of the lobe is in contact with the abdominal
parietes, and the edge may be felt as low, perhaps, as the navel. This ante-
version is apt to be mistaken for enlargement of the organ.
The " lacing " liver is met with in two chief types. In one the anterior
portion, chiefly of the right lobe, is greatly prolonged, and may reach the
transverse navel line, or even lower. A shallow transverse groove separates
the thin extension from the main portion of the organ. The peritoneal coat-
ing of this groove may be fibroid, and in rare instances the deformed portion
is connected with the organ by an almost tendinous membrane. The liver may
be compressed laterally and have a p^Tamidal shape, and the extreme left bor-
der and the hinder margin of the left lobe may be much folded and incurved.
The projecting portion of the liver, extending low in the right flank, may be
mistaken for a tumor, or more frequently for a movable right kidney. Its
continuity with the liver itself may not be evident on palpation or on percus-
sion, as coils of intestine may lie in front. It descends, however, with inspira-
tion, and usually the margin can be traced continuously with that of the left
lobe of the liver. The greatest difficulty arises when this anomalous lappet of
the liver is either naturally very thick and united to the liver by a very thin
membrane, or when it is swollen in conditions of great congestion of the
organ.
The other principal type of lacing liver is quite different in shape. It
is thick, broader above than below, and lies almost entirely above the trans-
verse line of the cartilages. There is a narrow groove just above the anterior
border, which is placed more transversely than normal.
Movable Liver. — This rare condition has received much attention, and
J. E. Graham collected 70 reported cases from the literature. In a very con-
siderable number of these there has been a mistaken diagnosis. A slight grade
of mobility of the organ is found in the pendulous abdomen of enteroptosis,
and after repeated asciteg.
The organ is so connected at its posterior margin with the inferior vena
cava and diaphragm that any great mobility from this point is impossible, ex-
cept on the theory of a meso-hepar or congenital ligamentous union between
these structures. The ligaments, however, may show an extreme grade of
relaxation (the suspensory 7.5 cm., and the triangular ligament 4 cm., in one
of Leube's cases) ; and when the patient is in the erect posture the organ may
drop down so far that its upper surface is entirely below the costal margin.
The condition is rarely met with in men; 56 of the cases were in women.
DISEASES OF THE PANCREAS. 573
I. DISEASES OF THE PANCREAS.
I, PANCREATIC INSUFFICIENCY.
Much attention has been given to the study of conditions in which the
secretions of the gland are defective. No one sign is distinctive, but a com-
bination gives a fairly accurate picture. The lesions are sclerosis, atrophy,
acute and chronic inflammatory changes, new growths and possibly functional
disturbances without obvious alterations of structure. The indications are,
1, Changes in the character of the stools; (a) an excess of total fat in the
fjeces, which in some cases has been as high as 90 per cent. The neutral fats
predominate in cases not associated with jaundice, (h) Diminution of the
tryptic energy, as shown by the failure to digest the nuclei of the muscle
fibres (Schmidt test) ; (c) imperfect digestion of the carbohydrates. The
stools are bulky, soft, acid, grayish white in color and have a peculiar odor.
2, Changes in the urine; (a) sugar is present in certain cases, as considered
under diabetes; (&) Cammidge's reaction. — In many lesions of the pancreas
this author claims that there is excreted by the kidneys a substance which in
hydrolysis gives the reaction of a pentose. The value' of this is still under
discussion; the results with the improved method have been favorable, (c)
The value of the presence in the urine of the fat-splitting ferment of Opie,
the Sahli reaction, of lipuria, and of maltosuria, has yet to be determined.
II. H^MOmiHAGE.
Both Spiess (1866) and Zenker (1874) were acquainted with haemor-
rhage into the pancreas as a cause of sudden death, but the great medico-legal
importance of the subject was first fully recognized by F. W. Draper, of Bos-
ton, whose townsmen, Harris, Fitz, Whitney, and others have contributed
additional studies. In 4,000 autopsies Draper met with 19 cases of pancreatic
hgemorrhage, in 9 or 10 of which no other cause of death was found. When
the bleeding is extensive the entire tissue of the gland is destroyed and the
blood invades the retro-peritoneal tissue. In other instances the peritoneal
covering is broken and the blood fills the lesser peritonaeum (see hsemoperito-
nseum). The hsemorrhage may be in connection with an acute pancreatitis or
with necrotic inflammation of the gland.
The symptoms are thus briefly summarized by Prince : " The patient who
has previously been perfectly well, is suddenly taken with the illness which
terminates his life. . . . When the haemorrhage occurs the patient may be
quietly resting or pursuing his usual occupation. The pain which ushers in
the attack is usually very severe and located in the upper part of the abdomen.
It steadily increases in severity, is sharp or perhaps colicky in character. It
is almost from the first accompanied by nausea and vomiting; the latter be-
comes frequent and obstinate, but gives no relief. The patient soon becomes
anxious, restless, and depressed; he tosses about, and only with difficulty can
. he be restrained in bed. The surface is cold and the forehead is covered with
a cold sweat. The pulse is weak, rapid, and sooner or later imperceptible. The
abdomen becomes tender, the tenderness being located in the upper part of the
574 DISEASES OF THE DIGESTIVE SYSTEM.
abdomen or epigastrmm. Tympanites is sometimes marked. The tempera-
ture is usually normal or subnormal. The bowels are apt to be constipated.
III. ACUTE PANCREATITIS.
(a) Acute Hsemorrhagic Pancreatitis. — In this form the inflammation is
combined with haemorrhage, and it is difficult to separate clearly the two proc-
esses.
Etiology. — A large majority of the cases occur in adult males. McPhed-
ran has reported one in a nine months' old child. Many of the patients had
been addicted to alcohol; others had suffered occasionally with severe pains
and vomiting or with gall-stone colic. Peiser found that 8 out of 131 col-
lected cases of acute pancreatitis were associated with parturition. He sug-
gests that the changes bringing about the pancreatitis in these cases may be
analogous to those occurring in the liver, kidneys, and other organs in eclamp-
sia. Miinzer, on the other hand, advances the hypothesis that the initial
necrosis may result from embolism with giant cells from the placenta.-
The pancreas is found enlarged, and the interlobular tissue infiltrated
with blood, and perhaps with clots. The relation of gall-stones to the con-
dition has been demonstrated in a recent case (Opie). A small calculus had
lodged in the diverticulum of Yater, closing its duodenal orifice and converting
the common bile duct and the duct of Wirsung into a closed channel. Bile
finding its way into the pancreas had caused hasmorrhagic inflammation. In-
jection of bile into the pancreatic ducts of dogs reproduces the lesion. The
gland cells have undergone more or less wide-spread necrosis, and at the mar-
gin of the necrotic areas are accumulations of inflammatory products, red
blood-corpuscles, polynuclear leucocytes, and fibrin. There can be seen about
the lobules and upon the omentum and mesentery opaque white specks, the
fat necroses of Balser.
Symptoms. — One of the most characteristic features is the suddenness of
the onset, usually with violent colicky pain in the upper part of the abdomen.
Nausea and vomiting follow, with collapse symptoms, more or less severe
according to the intensity of the attack. The abdomen becomes swollen and
tense and there is constipation. The temperature at first may be low; sub-
sequently fever sets in, sometimes initiated by a chill. There may be early
delirium. Collapse symptoms supervene, and death occurs usually from the
second to the fourth day, or even earlier. The swelling and infiltration in the
region of the pancreas necessarily involve the cceliac plexus, and the stretch-
ing of the nerves may account for the agonizing pain and the sudden col-
lapse. In a case which I have reported the semilunar ganglia were swollen,
the nerve-cells indistinct, and there was an interstitial infiltration of round
cells. The Pacinian corpuscles in the neighborhood of the pancreas were enor-
mously swollen and oedematous.
Deep pressure on the upper part of the abdomen may give evidence of
circumscribed resistance.
Diagnosis. — Intestinal obstruction or acute perforating peritonitis is usu-
ally suspected. Now that the condition has become better known the diagno-
sis intra vitam has been made. " Acute pancreatitis is to be suspected when
a previously healthy person or a sufferer from occasional attacks of indiges-
DISEASES OF THE PANCREAS. 575
tion is suddenly seized with a violent pain in the epigastrium followed by vom-
iting and collapse, and in the course of twenty-four hours by a circumscribed
epigastric swelling, tympanitic or resistant, with slight elevation of tempera-
ture. Circumscribed tenderness in the course of the pancreas and tender spots
throughout the abdomen are valuable diagnostic signs" (Fitz). An interest-
ing case admitted to the Johns Hopkins Hospital illustrates a common mis-
take. The young man had had symptoms of obstruction of the bowels .for
three or four days. The abdomen was distended, tender, and very painful.
I saw him on admission, agreed in the diagnosis of probable obstruction, and
ordered him to be transferred at once to the operating-room. Halsted found
no evidence of obstruction, but in the region of the pancreas and at the root
of the mesentery there was a dense, thick, indurated mass, and there were areas
of fat-necrosis in both mesentery and omentum. Oddly enough this patient
returned four years afterward with another attack, but he refused to be oper-
ated upon and was taken away by his friends.
(&) Acute Suppurative Pancreatitis — Pancreatic Abscess. — Fitz, in his
monograph in 1889, reported 33 cases. To this list Korte has added 34. Of
the cases, 33 were in males.
Etiology. — The etiology in a majority of cases is doubtful. Dyspeptic dis-
turbances and trauma have preceded the onset in some instances. In 34 cases
there was a single abscess ; in 14 there were numerous small abscesses. In other
instances there was a diffuse purulent infiltration. Some of the sequels are
peri-pancreatic abscess, perforation into the stomach, the duodenum, or the
peritonaeum, and thrombosis of the portal vein.
Symptoms. — The symptoms of suppurative pancreatitis are not always well
defined. In one case in my wards Thayer made a correct diagnosis. The
patient, aged thirty-four, had had occasional attacks of severe pain and vomit-
ing. This was followed by fever and delirium. A deep-seated mass was felt
in the median line just above the umbilicus. Finney operated and found dis-
seminated fat-necrosis and a deep-seated abscess with necrotic pancreatic tis-
sue. The patient recovered. The course of the suppurative form is much
more chronic. Icterus, fatty diarrhoea, and sugar in the urine have been met
with in some cases. The presence of a tumor mass in the epigastrium is of
the greatest moment.
(c) Gangrenous Pancreatitis. — Complete necrosis of the gland, or part of
it, may follow either haemorrhage or hgemorrhagic inflammation, and in excep-
tional cases may occur after suppurative infiltration or after injury or the
perforation of an ulcer of the stomach. In Fitz's monograph 15 cases are
reported. Korte has increased this number to 40. Symptoms of hgemorrhagic
pancreatitis may precede or be associated with it. Death usually follows in
from ten to twenty days, with symptoms of collapse.
Anatomically the pancreas may present a dry necrotic appearance, but as
a rule the organ is converted into a dark slaty-colored mass lying nearly free
in the omental cavity or attached by a few shreds. In other instances the
totally or partially sequestrated organ may lie in a large abscess cavity, form-
ing a palpable tumor in the epigastric region. In two cases, reported by Chiari,
the necrotic pancreas was discharged per rectum, with recovery.
Relation of Fat-necrosis to Pancreatic Disease. — In connection with all
forms of pancreatic disease small yellowish areas, to which Balser first directed
576 DISEASES OF THE DIGESTIVE SYSTEM.
attention, may be found in the interlobular pancreatic tissue, in the mesen-
tery, in the omentum, in the abdominal fatty tissue generally, and occasion-
ally in the pericardial and subcutaneous fat. It is stated that they may be
present without disease of the gland, but this is doubtful. They are most fre-
quent in the hemorrhagic and necrotic forms of pancreatitis, less common
in the suppurative. In. the pancreas the lobules are seen to be separated by a
dead-white necrotic tissue, which gives a remarkable appearance to the section.
In the abdominal fat the areas are usually not larger than a pin's head; they
at once attract attention, and may be mistaken, on superficial examination, for
miliary tubercles or neoplasms. They may be larger; instances have been re-
ported in which they were the size of a hen's egg. On section they have a soft,
tallow}^ consistence. E. Langerhans has shown that this substance is a com-
bination of lime with certain fatty acids. They may be crusted with lime,
and in a man, aged eighty, who died of Bright's disease, I found the lobules
of the pancreas entirely isolated by areas of fat-necrosis with extensive depo-
sition of lime salts. There is no necessary etiological relation between disease
of the pancreas and disseminated fat-necroses of the abdomen at the time
the latter are discovered. They have been found accidentally in laparotomy
for ovarian tumor and in instances in which the pancreas has been normal.
They may be present in thin persons or in association with gall-stones. Bacil-
lus coli was present in two instances, with diphtheritic colitis, examined by
Welch, though in most cases the areas of necrosis are sterile. Langerhans
produced fat-necrosis by injecting extract of pancreas into the peri-renal
fatty tissue of a dog ; and Hildebrand and Dettmer have shown experimentally
that the fat-necroses are caused by certain constituents of the pancreatic
juice, but not by trypsin. Flexner has demonstrated by chemical tests
the existence of the fat-splitting ferment in peritoneal fat-necroses in
recent human and experimental cases. The ferment (steapsin) disappears
after five or six days in experimental necroses, and can not be demonstrated
in the lime-incrusted human ones. H. U. Williams has produced similar
lesions in the subcutaneous fat by inserting bits of sterile pancreas beneath
the skin. By ligating the pancreatic ducts of cats Opie produced at the end of
several weeks necrosis of almost the entire abdominal fat, together with foci
in the subcutaneous tissue and in the pericardium. Flexner has produced acute
hemorrhagic pancreatitis by injecting artificial gastric juice into the duct of
Wirsung. Opie has recently made the interesting observation that hsemor-
rhagic pancreatitis and fat-necrosis may be produced by injecting bile into the
pancreatic duct of dogs, and has also shown that the penetration of bile into
the pancreas may be the cause of these conditions in human cases.
It is well for surgeons to remember that in two cases at least the most
serious symptoms of acute pancreatic disease have been found in association
only with wide-spread fat-necrosis of the gland. In a case reported by Stock-
ton and Williams a man, on his return journey from Europe, was seized with
vomiting and pain, without fever, but with a very small pulse. The patient
died soon after his arrival in America. The post mortem showed a pancreas
18 cm. long, at first sight normal, but on section most extensive fatty infiltra-
tion with fat-necrosis was demonstrable.
DISEASES OF THE PANCREAS. 577
IV. CHRONIC PANCREATITIS.
Anatomically there are two forms (a) interlobular, including that caused
by occlusion of the duct, and (&) interacinar, a more diffuse process invading
the islands of Langerhans, which are spared in the other forms. It is found
as a common condition, if microscopical examination is made. The organ is
enlarged and hard and the lobules stand out clearly. So hard may the gland
be that surgeons have frequently mistaken the enlarged and firm head for a
new growth. In the later stages the gland may be shrunken and cirrhotic.
Pancreatic calculi, gall-stones, infections of the duct (catarrhal by exten-
sion from the duodenum) are the common causes; a very typical form occurs
in hgemochromatosis. The symptoms are not very well defined. Many of
the most characteristic specimens have been met with accidentally. When due
to calculi and infection of the ducts there are pain, dyspepsia, fatty stools,
jaundice, at times fever, and loss of weight. The jaundice may be due to
compression of the head of the common bile-duct wher€ it passes through the
gland. Progressive wasting, the urinary reactions (Cammidge's in practised
hands) and jaundice are the most important diagnostic features, but at best
there is a good deal of uncertainty. It is quite possible, as Mayo Eobson sug-
gests, that many instances of so-called catarrhal jaundice are due to pressure
on the common duct by the swollen pancreatic tissue. From a surgical stand-
point jaundice is a most important symptom and was present in every one of
the 18 cases selected to illustrate the clinical course, etc., in Mayo Eobson and
Cammidge's work on the Pancreas. Drainage of the ducts and removal of
the stones are advised.
V. PANCREATIC CYSTS.
Of 121 cases operated upon by surgeons 60 were in males and 56 in
females; in 5 the sex was not given (Korte). Sixty-six of the cases occurred
in the fourth decade. T. C. Eailton's case (which is not in Korte's series),
an infant aged six months, and Shattuck's case in a child of thirteen and a
half months, are the youngest in the literature. According to the origin
Korte recognizes three varieties.
(1) Traumatic Cases. — In this list of 33 cases 30 were in men and only
3 in women. Blows on the abdomen or constantly repeated pressure are the
most common forms of trauma. One case followed severe massage. Usually
with the onset there are inflammatory symptoms, pain, and vomiting, some-
times suggestive of peritonitis. The contents of the cyst are usually bloody,
though in 13 of the traumatic cases it was clear or yellowish.
(3) Cysts following Inflammatory Conditions. — In 51 cases the trouble
began gradually after attacks of dyspepsia with colic, simulating somewhat
that of gall-stones. Occasionally the attack set in with very severe symptoms,
suggestive of obstruction of the bowel. In this group the tumor appeared in
19 cases soon after the onset of the pain ; in others it was delayed for a period
of from a few weeks to two or three years. McPhedran has reported a re-
markable instance in which the tumor appeared in the epigastrium with signs
of severe inflammation. It was opened and drained and believed to be a
578 DISEASES OF THE DIGESTIVE SYSTEM.
hydrops of the lesser peritoneal cavity. Three months later a second cyst
developed, which appeared to spring directly from the pancreas.
(3) Cysts without any Inflammatory or Traumatic Etiology. — Of 33 cases
in this group 36 were in women. A remarkable feature is the prolonged period
of their existence — in one case for forty-seven years, in one for between six-
teen and twenty years, in others for sixteen, nine, and eight years, in the major-
ity for from two to four years.
Morbid Anatomy. — Anatomically Korte recognizes ( 1 ) retention cysts due
to plugging of the main duct; (2) proliferation cysts of the pancreatic tissue —
the cysto-adenoma ; (3) retention cysts arising from the alveoli of the gland
and of the smaller ducts, which become cut off and dilate in consequence of
chronic interstitial pancreatitis; (4) pseudo-cysts follovv^ing inflammatory or
traumatic affections of the pancreas, usually the result of injury, causing h£em-
orrhage and hydrops of the lesser peritonaeum.
Situation. — In its growth the cyst may (1) be in the lesser peritonaeum,
push the stomach upward, and reach the abdominal wall between the stomach
and the transverse colon; (2) more rarely the cyst appears above the lesser
curvature and pushes the stomach downward; in both of these cases the situ-
ation of the tumor is high in the abdomen, but (3) it may develop between
the leaves of the transverse meso-colon and lie below both the colon and the
stomach. The relation of these two organs to the tumor is variable, but in
the majority of cases the stomach lies above and the transverse colon below the
cyst. Occasionally, too, as in T. C. Eailton's case, the cyst may arise in the
tail of the pancreas and project far over in the left hypochondrium in the
position of the spleen or of a renal tumor.
General Symptoms. — Apart from the features of onset already referred
to, the patient may complain of no trouble whatever, particularly in the very
chronic cases, unless the cyst reaches a very large size. Painful colicky attacks,
with nausea and vomiting and progressive enlargement of the abdomen, have
frequently been noted. Fatty diarrhoea from disturbance of the function of
the pancreas is rare. Sugar in the urine has been present in a number of
cases. Increased secretion of the saliva, the so-called pancreatic salivation,
is also rare. Pressure of the cyst may sometimes cause jaundice, and in rare
instances dyspnoea. Very marked loss of flesh has been present in a number
of cases. A remarkable feature often noticed has been the transitory disap-
pearance of the cyst. In one of Halsted's cases the girth of the abdomen de-
creased from 43 to 31 inches in ten days with profuse diarrhoea. Sometimes
the disappearance has followed blows.
Diagnosis. — The cyst occupies the upper abdomen, usually forming a
semicircular bulging in the median line, rarely to either side. In 16 cases
Korte states that the chief projection was below the navel. In one case oper-
ated upon by Halsted the tumor occupied the greater part of the abdomen.
The cyst is immobile, respiration having little or no influence on it. As already
mentioned, the stomach, as a rule, lies above it and the colon below.
In a majority of the cases the fluid is of a reddish or dark-brown color,
and contains blood or blood coloring matter, cell detritus, fat granules, and
sometimes cholesterin. The consistence of the fluid is usually mucoid, rarely
thin. The reaction is alkaline, the specific gravity from 1.010 to 1.020. In
22 cases Korte states that the fluid was not haemorrhagic.
DISEASES OF THE PANCREAS. 579
The existence of ferments is important. In 54 cases they were present
in the fluid or in the material from the fistula. In 20 cases only one ferment
was present, in 30 cases two, and in 14 cases all three of the pancreatic fer-
ments were found. In view of the wide occurrence of diastatic and fat-
emulsifying ferments in various exudates, the most important and only posi-
tive sign in the diagnosis of the pancreatic secretion is the digestion of fibrin
and albumin.
Operation. — ^Of 160 cases of operation there were 150 recoveries. Incision
and drainage was the operation performed in 138 cases, in 15 excision was
performed.
VI. TUMORS OF THE PANCREAS.
Of new growths in the organ carcinoma is the most frequent. Sarcoma,
adenoma, and lymphoma are rare.
Frequency. — At the General Hospital in Vienna in 18,069 autopsies there
were 23 cases of cancer of the pancreas (Biach). In 11,472 post mortems at
Milan, Segre found 132 tumors of the pancreas, 127 of which were carci-
nomata, 2 sarcomata, 2 cysts, and 1 syphiloma. In 6,000 autopsies at Guy's
Hospital there were only 20 cases of primary malignant disease of the organ
(Hale White). In the first 1,500 autopsies at the Johns Hopkins Hospital
there were 6 cases of adeno-carcinoma, and 1 doubtful case in which the exact
origin could not be stated. There were 8 cases of secondary malignant disease
of the pancreas. The head of the gland is most commonly involved, but the
disease may be limited to the body or to the tail. The majority of the patients
are in the middle period of life.
Symptoms. — The diagnosis is not often possible. The following are the
most important and suggestive features: (a) Epigastric pains, often occur-
ring in paroxysms. (&) Jaundice, due to pressure of the tumor in the head
of the pancreas on the bile-duct. The jaundice is intense and permanent, and
associated with dilatation of the gall-bladder, which may reach a very large
size, (c) The presence of a tumor in the epigastrium. This is very variable.
In 137 cases Da Costa found the tumor present in only 13. Palpation under
anaesthesia with the stomach empty would probably, give a very much larger
percentage. As the tumor rests directly upon the aorta there is usually a
marked degree of pulsation, sometimes with a bruit. There may be pressure
on the portal vein, causing thrombosis and its usual sequels, (d) Symptoms
due to loss of function of the pancreas are less important. Fatty diarrhoea is
not very often present. In consequence of the absence of bile the stools are
usually very clay-colored and greasy. Diabetes also is not common, (e) A
very rapid wasting and cachexia. Of other symptoms nausea and vomiting
are common. In some instances the pylorus is compressed and there is great
dilatation of the stomach. In a few cases there has been profuse salivation.
The points of greatest importance in the diagnosis are the intense and
permanent jaundice, with dilatation of the gall-bladder, rapid emaciation,
and the presence of a tumor in the epigastric region. Of less importance are
features pointing to disturbance of the function of the gland.
Of other new growths sarcoma and lymphoma have been occasionally
found. Miliary tubercle is not very uncommon in the gland. Syphilis may
580 DISEASES OF THE DIGESTIVE SYSTEM.
occur as rather a chronic interstitial inflammation, or in the form of gummata.
The outlook in tumors of the pancreas is, as a rule, hopeless. However,
of 10 cases operated upon of late years, 6 recovered (Korte).
VII. PANCREATIC CALCULI.
Pancreatic lithiasis is comparatively rare. In 1883 George W. Johnston
collected 35 cases in the literature. In 1,500 autopsies at the Johns Hopkins
Hospital there were 2 cases.
The stones are usually numerous, either round in shape or rough, spinous
and coral-like. The color is opaque white. They are composed chiefly of car-
bonate of lime. The effects of the stones are: (1) A chronic interstitial in-
flammation of the gland substance with dilatation of the duct ; sometimes there
is cystic dilatation of the gland; (2) acute inflammation with suppuration;
(3) the irritation of the stones, as in the gall-bladder, may lead to carcinoma.
Symptoms. — The cases are not often diagnosed. Pains in the epigastrium,
often very severe, but not characteristic; the signs of pancreatic insufficiency
already described, and the X-rays, which show the pancreatic but not the
biliary concretions, are suggestive features. An analysis of the calculi passed
with the stools may alone serve to distinguish a case from one of gall-stones.
Operation has been performed in five or six cases. In Mayo Eobson's case
the stones were removed from the duct of Wirsung.
J. DISEASES OE THE PERITONEUM.
I. ACUTE GENERAL PERITONITIS.
Definition. — Acute inflammation of the peritonaeum.
Etiology. — The condition may be primary or secondary.
(a) Primary, Idiopathic Peritonitis. — Considering how frequently the
pleura and pericardium are primarily inflamed the rarity of idiopathic in-
flammation of the peritonseum is somewhat remarkable. It may follow cold or
exposure and is then known as rheumatic peritonitis. No instance of the kind
has come under my notice. In Bright's disease, gout, and arterio-sclerosis
acute peritonitis may occur as a terminal event. Of 102 cases of peritonitis
which came to autopsy at the Johns Hopkins Hospital, 12 were of this form.
In these there was some pre-existing chronic disease (Flexner).
(h) Secondary peritonitis is due to extension of inflammation from, or
perforation of one of the organs covered by the peritonseum. Peritonitis from
extension may follow inflammation of the. stomach or intestines, extensive
ulceration in these parts, cancer, acute suppurative inflammations of the spleen,
liver, pancreas, retroperitoneal tissues, and the pelvic viscera.
Perforative peritonitis is the most common, following external wounds,
perforation of ulcer of the stomach or bowels, perforation of the gall-bladder,
abscess of the liver, spleen, or kidneys. Two important causes are appendi-
citis and suppurating inflammation about the Fallopian tubes and ovaries.
There are instances in which peritonitis has followed rupture of an appar-
ently normal Graafian follicle.
DISEASES OF THE PERITONEUM. 581
Of the above 103 cases, 56 originated in an extension from some diseased
abdominal viscus. The remaining 34 followed surgical operations upon the
peritonaeum or the contained organs.
The peritonitis of septicaemia and pyaemia is almost invariably the result
of a local process. An exceedingly acute form of peritonitis may be caused by
the development of tubercles on the membrane.
Morbid Anatomy. — In recent cases, on opening the abdomen the intes-
tinal coils are distended and glued together by lymph, and the peritonaeum
presents a patchy, sometimes a uniform injection. The exudation may be:
(a) Fibrinous, with little or no fluid, except a few pockets of clear serum
between the coils. (&) Sero-fibrinous. The coils are covered with lymph,
and there is in addition a large amount of a yellowish, sero-fibrinous fluid.
In instances in which the stomach or intestine is perforated this may be mixed
with food or faeces, (c) Purulent, in which the exudate is either thin and
greenish-yellow in color, or opaque white and creamy, (d) Putrid. Occa-
sionally in puerperal and perforative peritonitis, particularly when the latter
has been caused by cancer, the exudate is thin, grayish-green in color, and
has a gangrenous odor, (e) Haemorrhagic. This is sometimes found as an
admixture in cases of acute peritonitis following wounds, and occurs in the
cancerous and tuberculous forms. (/) A rare form occurs in which the injec-
tion is present, but almost all signs of exudation are wanting. Close inspection
may be necessary to detect a slight dulling of the serous surfaces.
The amount of the effusion varies from half a litre to 20 or 30 litres.
There are probably essential differences between the various kinds of peri-
tonitis.
Bacteriology of Acute Peritonitis. — Much work has been done lately upon
the subject. Flexner has analyzed 103 cases of peritonitis, in which bacterio-
logical studies were made, which came to autopsy in the Johns Hopkins Hos-
pital. He makes three classes. The first class embraces the primary or idio-
pathic form, of which 13 cases were found. These were with one exception
mono-infections. The prevailing micro-organism was the streptococcus pyog-
enes (five times), the remaining ones being the staphylococcus aureus, micro-
coccus lanceolatus, bacillus proteus, pyocyaneus, coli communis, and the in-
fluenza bacillus. The second class followed operations upon the peritonaeum,
excepting operations upon the intestine. The majority of these cases were
examples of wound infection. They were 33 in number. In 35 of these mono-
infections, in 8 mixed infections existed. The prevailing micro-organism was
the staphylococcus aureus, which was present alone in 13 and combined in 3
cases. The streptococcus occurred 5 times uncombined and 4 times com-
bined. The bacillus coli was found 5 times in all, being unassociated in 3
cases. Other organisms found were the micrococcus lanceolatus, staphylococcus
albus, bacillus pyocyaneus, and aerogenes capsulatus. The remaining 56 cases,
forming the third class, were instances of intestinal infection. These com-
prised 33 mono- and 33 polyinfections. The predominating micro-organism
was the bacillus coli communis which occurred in 43 cases, 8 times alone and
35 in association. The streptococcus was present in 37 cases, being alone in 7.
The staphylococci, pneumococcus, bacillus proteus, pyocyaneus, typhosus, and
aerogenes capsulatus occurred in a smaller number of instances.
Among the micro-organisms thus far found rarely in peritonitis, may be
582 DISEASES OF THE DIGESTIVE SYSTEM.
mentioned the gonocoecus, the anthrax bacillus, the proteus bacillus, and the
typhoid bacillus. The gonorrhoeal form arises from salpingitis and may occur
in children. Welch has found the bacillus coli communis in peritonitis due
to ulceration of the intestines without perforation.
Symptoms. — In the perforative and septic cases the onset is marked by
chilly feelings or an actual rigor with intense pain in the abdomen. In typhoid
fever, when the sensorium is benumbed, the onset may not be noticed. The
pain is general, and is usually intense and aggravated by movements and pres-
sure. A position is taken which relieves the tension of the abdominal mus-
cles, so that the patient lies on the back with the thighs drawn up and the
shoulders elevated. The greatest pain is usually below the umbilicus, but in
peritonitis from perforation of the stomach pain may be referred to the back,
the chest, or the shoulder. The respiration is superficial — costal in type —
as it is painful to use the diaphragm. For the same reason the action of
coughing is restrained, and even the movements necessary for talking are lim-
ited. In this early stage the sensitiveness may be great and the abdominal
muscles are often rigidly contracted. If the patient is at perfect rest the pain
may be very slight, and there are instances in which it is not at all marked,
and may, indeed, be absent.
The abdomen gradually becomes distended and tense and is tympanitic on
percussion. The pulse is rapid, small, and hard, and often has a peculiar wiry
quality. It ranges from 110 to 150, The temperature may rise rapidly after
the chill and reach 104° or 105°, but the subsequent elevation is moderate.
In some very severe cases there may be no fever throughout. The tongue at
first is white and moist, but subsequently becomes dry and often red and fis-
sured. Vomiting is an early and prominent feature and causes great pain. The
contents of the stomach are first ejected, then a yellowish and bile-stained
fluid, and finally a greenish and, in rare instances, a brownish-black liquid with
slight fffical odor. The bowels may be loose at the onset and then constipa-
tion may follow. Frequent micturition may be present, less often retention.
The urine is usually scanty and high-colored, and contains a large quantity
of indican.
The appearance of the patient when these symptoms have fully developed
is very characteristic. The face is pinched, the eyes are sunken, and the expres-
sion is very anxious. The constant vomiting of fiuids causes a wasted appear-
ance, and the hands sometimes present the washer-woman's skin. Except in
cholera, we see the Hippocratic facies more frequently in this than in any
other disease — " a sharp nose, hollow eyes, collapsed temples; the ears cold,
contracted, and their lobes turned out; the shin about the forehead being rough,
distended, and parched; the color of the whole face being brown, black, livid,
or lead-colored." There are one or two additional points about the abdomen.
The tympany is usually excessive, owing to the great relaxation of the walls of
the intestines by inflammation and exudation. The splenic dulness may be
obliterated, the diaphragm pushed up, and the apex beat of the heart dislo-
cated to the fourth interspace. The liver dulness may be greatly reduced, or
may, in the mammary line, be obliterated. It has been claimed that this is a
distinctive feature of perforative peritonitis, but on several occasions I have
been able to demonstrate that the liver dulness in the middle and mammary
line was obliterated by tympanites alone. In the axillary line, on the other
DISEASES OF THE PERITONEUM. 583
hand, the liver dulness, though diminished, may persist. Pneumo-peritongeum
following perforation more certainly obliterates the hepatic dulness. In such
cases the fluid efi^used produces a dulness in the lateral regions; but with gas
in the peritonaeum, if the patient is turned on the left side, a clear note is
heard beneath the seventh and eighth ribs. Acute peritonitis may present a
flat, rigid abdomen throughout its course.
Effusion of fluid — ascites — is usually present except in some acute rapidly
fatal cases. The flanks are dull on percussion. The dulness may be movable,
though this depends altogether upon the degree of adhesions. There may be
considerable effusion without either movable dulness or fluctuation. A fric-
tion-rub may be present, as first pointed out by Bright, but it is not nearly so
common in acute as in chronic peritonitis.
Course. — The acute diffuse peritonitis usually terminates in death. The
most intense forms may kill within thirty-six to forty-eight hours ; more com-
monly death results in four or five days, or the attack may be prolonged to
eight or ten days. The pulse becomes irregular, the heart-sounds weak, the
breathing shallow; there are lividity with pallor, a cold skin with high rectal
temperature — a group of symptoms indicating profound failure of the vital
functions for which Gee has revived the old term lipothyvtia. Occasion-
ally death occurs with great suddenness, owing, possibly, to paralysis of the
heart.
Diagnosis. — In typical cases the severe pain at onset, the distention of the
abdomen, the tenderness, the fever, the gradual onset of effusion, collapse,
and the vomiting give a characteristic picture. Careful inquiries should at
once be made concerning the previous condition, from which a clew can often
be had as to the starting-point of the trouble. In young adults a considerable
proportion of all cases depends upon perforating appendicitis, and there may
be an account of previous attacks of pain in the iliac region, or of constipa-
tion alternating with diarrhoea. In women the most frequent causes are sup-
purative processes in the pelvic viscera, associated with salpingitis, abscesses
in the broad ligaments, or acute puerperal infection. Perforation of gastric
ulcer is a more common factor in women than in men. It is not always easy
to determine the cause. Many cases come under observation for the first time
with the abdomen distended and tender, and it is impossible to make a satis-
factory examination. In such instances the pelvic organs should be examined
with the greatest care. In typhoid fever, if the patient is conscious, the sud-
den onset of pain, the tenderness, rigidity, muscle spasm, and the aggravation
of the general symptoms indicate what has happened. When the patient is
in deep coma, on the other hand, the perforation may be overlooked. The fol-
lowing conditions are most apt to be mistaken for acute peritonitis :
(a) Acute Entero-colitis. — Here the pain and distention and the sensitive-
ness on pressure may be marked. The pain is more colicky in character, the
diarrhoea is more frequent, and the collapse is more extreme.
(&) The So-called Hysterical Peritonitis. — This has deceived the very
elect, as almost every feature of genuine peritonitis, even the collapse, may
be simulated. The onset may be sudden, with severe pain in the abdomen,
tenderness, vomiting, diarrhoea, difficulty in micturition, and the character-
istic decubitus. Even the temperature may be elevated. There may be recur-
rence of the attack. A case has been reported by Bristowe in which four
584 DISEASES OF THE DIGESTIVE SYSTEM.
attacks occurred within a year, and it was not until special hysterical symp-
toms developed that the true nature of the trouble was suspected.
(c) Obstruction of the Ijowel, as already mentioned, may simulate perito-
nitis, both having pain, vomiting, tympanites, and constipation in common.
It may for a couple of days really be impossible to make a diagnosis in the
absence of a satisfactory history.
{d) Rupture of an abdominal aneurism or embolism of the superior mes-
enteric artery may cause symptoms which simulate peritonitis. In the latter,
sudden onset with severe pain, the collapse s3rmptoms, frequent vomiting, and
great distention of the abdomen may be present.
(e) I have already referred to the fact that acute hsemorrhagic pancre-
atitis may be mistaken for peritonitis. Lastly, a ruptured tubal pregnancy
may resemble acute peritonitis.
II. PERITONITIS IN INFANTS.
Peritonitis may occur in the foetus as a consequence of syphilis, and may
lead to constriction of the bowel by fibrous adhesions.
In the new-born a septic peritonitis may extend from an inflamed cord.
Distention of the abdomen, slight swelling and redness about the cord, and
not infrequently jaundice are present. It is an uncommon event, and existed
in only 4 of 51 infants dying with inflammation of the cord and septicaemia
(Eunge). • . . . .
During childhood peritonitis arises from causes similar to those affect-
ing the adult. Perforative appendicitis is common. Peritonitis following
blows or kicks on the abdomen occurs more frequently at this period. In
boys injury while playing foot-ball may be followed by diffuse peritonitis. A
rare cause in children is extension through the diaphragm from an empyema.
There are on record instances of peritonitis occurring in several children at
the same school, and it has been attributed to sewer-gas poisoning. It was in
investigating an epidemic of this kind at the Wandsworth school, in London,
that Anstie received the post-mortem wound of which he died. It is to be
remembered that peritonitis in children may follow the gonorrhoeal vulvitis
so common in infant homes and hospitals.
III. LOCALIZED PERITONITIS.
1. Subphrenic Peritonitis. — The general peritona3um covering the right
and left lobes of the liver may be involved in an extension from the pleura
of suppurative, tuberculous, or cancerous processes. In various affections
of the liver — cancer, abscess, hydatid disease, and in affections of the gall-
bladder— the inflammation may be localized to the peritonaeum covering the
upper surface of the organ. These forms of localized subphrenic peritonitis
in the greater sac are not so important in reality as those which occur in the
lesser peritonaeum. The anatomical relations of this structure are as follows :
It lies behind and below the stomach, the gastro-hepatic omentum, and the
anterior layer of the great omentum. Its lower limit forms the upper layer
of the transverse meso-colon. On either side it reaches from the hepatic to
the splenic flexure of the colon, and from the foramen of Winslow to the
DISEASES OF THE PERITONAEUM. 585
hilus of the spleen. Behind it covers and is tightly adherent to the front of
the pancreas. Its upper limit is formed by the transverse fissure of the liver,
and by that portion of the diaphragm which is covered by the lower layer of the
right lateral ligament of the liver; the lobus Spigelii lies bare in the cavity.
The foramen of Winslow, through which the lesser communicates with the
greater peritonasum, is readily closed by inflammation.
Inflammatory processes, exudates, and haemorrhages may be confined en-
tirely to the lesser peritonaeum. The exudate of tuberculous peritonitis may
be confined to it. Perforations of certain parts of the stomach, of the duode-
num, and of the colon may excite inflammation in it alone; and in various
affections of the pancreas, particularly trauma and haemorrhage, the effusion
into the sac has often been confounded with cyst of this organ. " Pathological
distention of the lesser peritonaeum gives rise to a tumor in the left hypo-
chondriac, epigastric, and umbilical regions of a somewhat characteristic shape,
but which appears to vary from time to time in form and size, according to
the conditions of the overlying stomach; for when the viscus is full of liquid
contents it increases the area of the tumor's dulness, while it makes its out-
lines less definable by palpation, and if the stomach is distended with gas the
dull area becomes resonant and apparently the tumor may disappear alto-
gether. The colon always lies below the tumor and never in front of or above
it, as is the case in kidney enlargement " (Jordan Lloyd),
Special mention must be made of the remarkable form of subphrenic
abscess containing air, which may simulate closely pneumothorax, and hence
was called by Leyden Pyo-pneumotliorax subplirenicus. The affection has
been thoroughly studied of late years by Scheurlen, Mason, Meltzer, and Lee
Dickinson. In 143 out of 170 recorded cases the cause was known. In a few
instances, as in one reported by Meltzer, the subphrenic abscess seemed to have
followed pneumonia. Pyothorax is an occasional cause. By far the most fre-
quent condition is gastric ulcer, which occurred in 80 of the cases. Duodenal
ulcer was the cause in 6 per cent. In about 10 per cent of the cases the appen-
dix was the starting-point of the abscess. Cancer of the stomach is an occa-
sional cause. Other rare causes are trauma, which was present in one of my
cases, perforation of an hepatic or a renal abscess, lesions of the spleen,
abscess, and cysts of the pancreas.
In a majority of all the cases in which the stomach or duodenum is per-
forated— sometimes, indeed, in the cases following trauma, as in Case 3 of my
series — the abscess contains air.
The symptoms of subphrenic abscess vary very considerably, depending
a good deal upon the primary cause. The onset, as a rule, is abrupt, particu-
larly when due to perforation of a gastric ulcer. There are severe pain, vom-
iting, often of bilious or of bloody material ; respiration is embarrassed, owing
to the involvement of the diaphragm ; then the constitutional symptoms occur
associated with suppuration, chills, irregular fever, and emaciation. Subse-
quently perforation may take place into the pleura or into the lung, with severe
cough and abundant purulent expectoration.
The conditions are so obscure that the diagnosis of subphrenic abscess is
not often made. The perihepatic abscess beneath the arch of the diaphragm,
whether to the right or left of the suspensory ligament, when it does not contain
air, is almost invariably mistaken for empyema. When a pus collection of
586 DISEASES OF THE DIGESTIVE SYSTEM.
any size is in the lesser peritonEeum, the tumor is formed which has the char-
acters alread}' mentioned in a quotation from Mr. Jordan Lloyd.
The most remarkable features are those which are superadded when the
abscess cavity contains air. Here^ on the right side, when the abscess is in
the greater peritonasum, above the right lobe of the liver, the diaphragm may
be pushed up to the level of the second or third rib, and the physical signs on
percussion and auscultation are those of pneumothorax, particularly the tym-
panitic resonance and the movable dulness. The liver is usually greatly de-
pressed and there is bulging on the right side. Still more obscure are the
cases of air-containing abscesses due to perforation of the stomach or duode-
num, in which the gas is contained in the lesser peritongeum. Here the dia-
phragm is pushed up and there are signs of pneumothorax on the left side.
In a large majority of all the cases which follow perforation of a gastric ulcer
the effusion lies between the diaphragm above, and the spleen, stomach, and
the left lobe of the liver below.
The prognosis in subphrenic abscess is not very hopeful. Of the cases on
record about 20 per cent only have recovered.
2. Appendicular. — The most frequent cause in the male of localized peri-
tonitis is inflammation of the appendix vermiformis. The situation varies
with the position of this extremely variable organ. The adhesion, perforation,
and intraperitoneal abscess cavity may be within the pelvis, or to the left of
the median line in the iliac region, in the lower right quadrant of the umbil-
ical region — a not uncommon situation — or, of course, most frequentlj^ in the
right iliac fossa. In the most common situation the localized abscess lies upon
the psoas muscle, bounded by the caecum on the right and the terminal por-
tion of the ileum and its mesentery in front and to the left. In many of these
cases the limitation is perfect, and post-mortem records show that complete
healing may take place with the obliteration of the appendix in a mass of
firm scar tissue.
3. Pelvic Peritonitis. — The most frequent cause is inflammation about the
uterus and Fallopian tubes. Puerperal septicsemia, gonorrhoea, and tubercu-
losis are the usual causes. The tubes are the starting-point in a majority
of the cases. The fimbria become adherent and closely matted to the ovary,
and there is gradually produced a condition of thickening of the parts, in
which the individual organs are scarcely recognizable. The tubes are dilated
and filled with cheesy matter or pus, and there may be small abscess cavities
in the broad ligaments. Eupture of one of these may cause general perito-
nitis, or the membrane may be involved by extension, as in tuberculosis of
these parts.
IV. CHRONIC PERITONITIS.
The following varieties may be recognized :
(a) Local adhesive peritonitis, a very common condition, which occurs
particularly about the spleen, forming adhesions between the capsule and the
diaphragm, about the liver, less frequently about the intestines and mesen-
tery. Points of thickening or puckering on the peritoneum occur sometimes
with union of the coils or with fibrous bands. In a majority of such cases the
condition is met accidentally post mortem. Two sets of s3Tnptoms may, how-
ever, be caused by these adhesions. When a fibrous band is attached in such
DISEASES OF THE PERITONMVM. 587
a way as to form a loop or snare, a coil of intestine may pass through it. Thus,
of the 295 cases of intestinal obstruction analyzed by Fitz, 63 were due to
this cause. The second group is less serious and comprises cases with persist-
ent abdominal pain of a colicky character, sometimes rendering life miserable.
(&) Diffuse Adhesive Peritonitis. — This is a consequence of an acute in-
flammation, either simple or tuberculous. The peritoneum is obliterated. On
cutting through the abdominal wall, the coils of intestines are uniformly
matted together and can neither be separated from each other nor can the
visceral and parietal layers be distinguished. There may be thickening of the
layers, and the liver and spleen are usually involved in the adhesions.
(c) Proliferative Peritonitis. — Apart from cancer and tubercle, which pro-
duce typical lesions of chronic peritonitis, the most characteristic form is that
which may be described under this heading. The essential anatomical feature
is great thickening of the peritoneal layers, usually without much adhesion.
The cases are sometimes seen with sclerosis of the stomach. In one instance
I found it in connection with a sclerotic condition of the caecum and the first
part of the colon. It is not uncommon with cirrhosis of the liver. In the
inspection of a case of this kind there is usually moderate effusion, more rarely
extensive ascites. The peritoneum is opaque- white in color, and everywhere
thickened, often in patches. The omentum is usually rolled and forms a
thickened mass transversely placed between the stomach and the colon. The
peritoneum over the stomach, intestines, and mesentery is sometimes greatly
thickened. The liver and spleen may simply be adherent, or there is a con-
dition of chronic perihepatitis or perisplenitis, so that a layer of firm, almost
gristly connective tissue of from one-fourth to half an inch in thickness encir-
cles these organs. Usually the volume of the liver is in consequence greatly
reduced. The gastro-hepatic omentum may be constricted by this new growth
and the calibre of the portal vein much narrowed. A serous effusion may be
present. On account of the adhesions which form, the peritoneum may be
divided into three or four different sacs, as is more fully described under the
tuberculous peritonitis. In these cases the intestines are usually free, though
the mesentery is greatly shortened. There are instances of chronic peritonitis
in which the mesentery is so shortened by this proliferative change that the
intestines form a ball not larger than a cocoa-nut situated in the middle line,
and after the removal of the exudation can be felt as a solid tumor. The
intestinal wall is greatly thickened and the mucous membrane of the ileum
is thrown into folds like the valvule conniventes. This proliferative perito-
nitis is found frequently in the subjects of chronic alcoholism. In cases of
long-continued ascites the serous surfaces generally become thickened and pre-
sent an opaque, dead-white color. This condition is observed especially in
hepatic cirrhosis, but attends tumors, chronic passive congestion, etc.
In all forms of chronic peritonitis a friction may be felt usually in the
upper zone of the abdomen. Polyorrhomenitis, polyserositis, general chronic
inflammation of the serous membranes, Concato's disease (as the Italians call
it), may occur with this form as well as in the tuberculous variety. The peri-
cardium and both pleure may be involved.
In some instances of chronic peritonitis the membrane presents numer-
ous nodular thickenings, which may be mistaken for tubercles. J. F. Payne
has described a case of this sort associated with disseminated growths through-
588 DISEASES OF THE DIGESTIVE SYSTEM.
out the liver vhich were not cancerous. It has been suggested that some of
the cases of tuberculous peritonitis cured by operation have been of this
nature, but histological exaniination would, as a rule, readily determine be-
tvreen the conditions. Miura, in Japan, has reported a case in which these
nodules contained the ova of a parasite. One case has been reported in which
the exciting cause was regarded as cholesterin plates, which were contained
within the granulomatous nodules.
(d) Chronic Haemorrhagic Peritonitis. — Blood-stained effusions in the
peritonseum occur particularly in cancerous and tuberculous disease. There
is a form of chronic inflammation analogous to the haemorrhagic pachymen-
ingitis of the brain. It was described first by Yirchow, and is localized most
commonly in the pelvis. Layers of new connective tissue form on the surface
of the peritonseum with large wide vessels from which haemorrhage occurs.
This is repeated from time to time with the formation of regular layers of
hsemorrhagic effusion. It is rarely diffuse, more commonly circumscribed.
V. NEW GROWTHS IN THE PERITON-ffiXJM.
(a) Tuberculous Peritonitis. — This has already been considered.
(&) Cancer of the Peritonaeum. — Although, as a rule, secondary to disease
of the stomach, liver, or pelvic organs, cases of primary cancer have been
described. It is probable that the so-called primary cancers of the serous
membranes are endotheliomata and not carcinomata. Secondary malignant
peritonitis occurs in connection with all forms of cancer. It is usually char-
acterized by a number of round tumors scattered over the entire peritoneum,
sometimes small and miliary, at other times large and nodular, with puckered
centres. The disease most commonly starts from the stomach or the ovaries.
The omentum is indurated, and, as in tuberculous peritonitis, forms a mass
which lies transversely, across the upper portion of the abdomen. Primary
malignant disease of the peritonasum is extremely rare. Colloid is said to
have occurred, forming enormous masses, which in one case weighed over 100
pounds. Cancer of this membrane spreads, either by the detachment of small
particles which are carried in the lymph currents and by the movements to
distant parts, or by contact of opposing surfaces. It occurs more frequently
in women than in men, and more commonly at the later period of life.
The diagnosis of cancer of the peritongeum is easy with a history of a
local malignant disease ; as when it occurs with ovarian tumor or with cancer
of the pylorus. In cases in which there is no evidence of a primary lesion the
diagnosis may be doubtful. The clinical picture is usually that of chronic
ascites with progressive emaciation. There may be no fever. If there is much
effusion nothing definite can be felt on examination. After tapping, irregular
nodules or the curled omentum may be felt lying transversely across the upper
portion of the abdomen. Unfortunately, this tumor upon which so much stress
is laid occurs as frequently in tuberculous peritonitis and may be present in
a typical manner in the chronic proliferative form, so that in itself it has no
special diagnostic value. Multiple nodules, if large, indicate cancer, particu-
larly in persons above middle life. Modular tuberculous peritonitis is most
frequent in children. The presence about the navel of secondary nodules and
indurated masses is more common in cancer. Inflammation, suppuration, and
DISEASES OF THE PERITONEUM. 589
the discharge of pus from the navel rarely occurs except in tuberculous disease.
Considerable enlargement of the inguinal glands may be present in cancer.
The nature of the fluid in cancer and in tubercle may be much alike. It may
be hsemorrhagic in both ; more often in the latter. The histological examina-
tion in cancer may show large multinuclear cells or groups of cells — the
sprouting cell-groups of Foulis — which are extremely suggestive. The colloid
cancer may produce a totally different picture; instead of ascitic fluid, the
abdomen is occupied by the semi-solid gelatinous substance, and is firm, not
fluctuating.
And, lastly, there are instances of echinococci in the peritonaeum which
may simulate cancer very closely.
VI. ASCITES (Hydro-peritonaeiini).
Definition. — The accumulation of serous fluid in the peritoneal cavity.
Etiology. — (1) Local Causes. — (a) Chronic inflammation of the peri-
toneum, either simple, cancerous, or tuberculous. (&) Portal obstruction in
the terminal branches within the liver, as in cirrhosis and chronic passive
congestion, or by compression of the vein in the gastro-hepatic omentum,
either by proliferative peritonitis, by new growths, or by aneurism, (c) Throm-
bosis of the portal vein, (d) Tumors of the abdomen. The solid growths
of the ovaries may cause considerable ascites, which may completely mask the
true condition. The enlarged spleen in leukaemia, less commonly in malaria,
may be associated with recurring ascites.
(2) Geneeal Causes. — The ascites is part of a general dropsy, the result
of mechanical effects, as in heart-disease, chronic emphysema, and sclerosis
of the lung. In cardiac lesions the effusion is sometimes confined to the peri-
tonaeum, in which case it is due to secondary changes in the liver, or it has
been suggested to be connected with a failure of the suction action of this
organ, by which the peritonaeum is kept dry. Ascites occurs also in the dropsy
of Bright's disease, and in hydrsemic states of the blood.
Symptoms. — A gradual uniform enlargement of the abdomen is the char-
acteristic symptom of ascites. The physical signs are usually distinctive,
(a) Inspection. — According to the amount of fluid the abdomen is protu-
berant and flattened at the sides. With large effusions, the skin is tense and
may present the lineae albicantes. Frequently the navel itself and the parts
about it are very prominent. In many cases the superficial veins are enlarged
and a plexus joining the mammary vessels can be seen. Sometimes it can
be determined by pressure on these veins that the current is from below upward.
In some instances, as in thrombosis or obliteration of the portal vein, these
superficial abdominal vessels may be extensively varicose. About the navel
in cases of cirrhosis there is occasionally a large bunch of distended veins, the
so-called caput Medusae. The heart may be displaced upward.
(&) Palpation. — Fluctuation is obtained by placing the fingers of one
hand upon one side of the abdomen and by giving a sharp tap on the opposite
side with the other hand, when a wave is felt to strike as a definite shock
against the applied fingers. Even comparatively small quantities of fluid
may give this fluctuation shock. When the abdominal walls are thick or very
fat, an assistant may place the edge of the hand or a piece of cardboard in
590 DISEASES OF THE DIGESTIVE SYSTEM.
•
front of the abdomen. A different procedure is adopted in palpating for
the solid organs in case of ascites. Instead of placing the hand flat upon the
abdomen, as in the ordinary method, the pads of the fingers only are placed
lightly upon the skin, and then by a sudden depression of the fingers the fluid
is displaced and the solid organ or tumor may be felt. By this method of
" dipping " or displacement, as it is called, the liver may be felt below the
costal margin, or the spleen, or sometimes solid tumors of the omentum or
intestine.
(c) Percussion. — In the dorsal position with a moderate quantity of fluid
in the peritongeum the flanks are dull, while the umbilical and epigastric
regions, into which the intestines float, are tympanitic. This area of clear
resonance may have an oval outline. Having obtained the lateral limit of the
dulness on one side, if the patient turns on the opposite side, the fluid gravi-
tates to the dependent part and the uppermost flank is now tympanitic. In
moderate effusions this movable dulness changes greatly in the different pos-
tures. Small amounts of fluid, probably under a litre, would scarcely give
movable dulness, as the pelvis and the renal regions hold a considerable quan-
tity. In such cases it is best to place the patient in the knee-elbow position,
when a dull note will be determined at the most dependent portion. By care-
ful attention to these details mistakes are usually avoided.
The following are among the conditions which may be mistaken for dropsy :
Ovarian tumor, in which the sac develops, as a rule, unilaterally, though when
large it is centrally placed. The dulness is anterior and the resonance is in
the flanks, into which the intestines are pushed by the cyst. Examination per
vaginam may give important indications. In those rare instances in which
gas develops in the cyst the diagnosis may be very difficult. Succussion has
been obtained in such cases. A distended bladder may reach above the umbil-
icus. In such instances some urine dribbles away, and suspicion of ascites
or a cyst is occasionally entertained. I once saw a trocar thrust into a dis-
tended bladder, which was supposed to be an ovarian cyst, and it is stated that
John Hunter tapped a bladder, supposing it to be ascites. Such a mistake
should be avoided by careful catheterization prior to any operative procedures.
And lastly, there are large pancreatic or hydatid cysts in the abdomen which
may simulate ascites.
Nature of the Ascitic Fluid. — ^Usually this is a clear serum, light yellow
in the ascites of ansemia and Bright's disease, often darker in color in cirrho-
sis of the liver. The specific gravity is low, seldom more than 1.010 or 1.015,
whereas in the fluid of ovarian cysts or chronic peritonitis the specific gravity
is over 1.015. It is albuminous and sometimes coagulates spontaneously.
Dock has called attention to the importance of the study of the cells in the
exudate. In cancer very characteristic forms, with nuclear figures, may be
found. Hsemorrhagic effusion usually occurs in cancer and tuberculosis, and
occasionally in cirrhosis. I have already referred to the instances of haem-
orrhagic effusion in connection with ruptured tubal pregnancy.
A chylous, milky exudate is occasionally found. There are, as Quincke
has pointed out, two distinct varieties, a fatty and a chylous, which may be
distinguished by the microscope, as in the former there are distinct fat-glob-
ules. These cases have been sometimes connected with peritoneal or mesen-
teric cancer. In the true chylous ascites the fluid is turbid and milky. In
DISEASES OF THE PERITONEUM. 591
some of the cases, as in Whitla's, a perforation of the thoracic duct has been
found, but the condition does not necessarily follow obliteration of the thoracic
duct. Mild grades of chylous ascites, which are occasionally found clinically,
may be due to the fact that the patient upon a milk diet has a permanent
lipaemia, such as is present in young animals and in diabetics, in whom
the liquor sanguinis is always fatty. Under such circumstances an exu-
date may contain enough of the molecular base of the chyle to produce turbid-
ity of the fluid. Some of the cases have been associated with filariasis.
Treatment of the Previous Conditions. — (a) Acute Peritonitis. — Rest
is enjoined upon the patient by the severe pain which follows the slightest
movement, and he should be propped in the position which gives him greatest
relief. Whether morphia should be given will depend upon the cause. In
the pain of appendicitis and of perforation in typhoid fever it is best to use
an ice-bag and withhold the drug. Late in the disease and in hopeless condi-
tions it may be given freely. The opium treatment so strongly advocated by
the late Alonzo Clark has gone out of vogue.
Local applications — the ice-bag, hot turpentine stupes, or cloths wrung
out of ice-water — may be laid upon the abdomen.
The question of the use of purgatives in peritonitis has of late been warmly
discussed. Theoretically it appears correct to give salines in concentrated
form, which cause a rapid and profuse exosmosis of serum from the intestinal
vessels, relieving the congestion and reducing the oedema, which is one impor-
tant factor in causing the meteorism. It is also urged that the increased peri-
stalsis prevents the formation of adhesions. In reading the reports of these
successful cases, one is not always convinced, however, that peritonitis actually
existed. Still, in cases of acute peritonitis due to extension or following oper-
ation or in septic conditions the judgment of many careful men is decidedly
in favor of the use of salines. The majority of cases of peritonitis which come
under the care of the physician follow lesions of the abdominal viscera or are
due to perforation of ulcer of the stomach, the ileum, or the appendix. In
such cases, particularly in the large group of appendix cases, to give saline
purgatives is, to say the least, most injudicious treatment. In these instances
rectal injections should be employed to relieve the large bowel. No symptom
in acute peritonitis is more serious than the tympanites, and none is more
difficult to meet. The use of the long tube and injections containing turpen-
tine may be tried. Drugs by the mouth can not be retained.
For the vomiting, ice and small quantities of soda water may be employed.
The patient should be fed on milk, but if the vomiting is distressing it is best
not to attempt to give food by the mouth, but to use small nutrient enemata.
In all cases it is best to have a surgeon in consultation early in the disease,
as the question of operation may come up at any moment. In the acute forms
of tuberculous peritonitis operative measures appear to be more hopeful, but
they are not always successful.
(&) Cheonic Peritonitis. — For the cases of chronic proliferative perito-
nitis very little can be done. The treatment is practically that of ascites. In
all these forms, when the distention becomes extreme, tapping is indicated.
The treatment of tubercnlous peritonitis has fallen largely into the hands of
the surgeons, but the results depend on the stage at which the operation is
performed and the variety of the disease. With ascites the outlook is good;
592 DISEASES OF THE DIGESTIVE SYSTEM.
but when there are tuberculous tumors and man}- adhesions the results are
not very satisfactory. Maurice Eichardson, in a child aged tive, with a sus-
pected appendicitis (tumor, etc.), found the s}Tnptoms to be due to enlarged,
tuberculous mesenteric glands, which were removed, and the boy remained well
five years after the operation.
(c) Ascites. — The treatment depends somewhat on the nature of the case.
In cirrhosis early and repeated tapping may give time for the establishment
of the collateral circulation, and temporary cures have followed this procedure.
Permanent drainage with Southe}''s tube, incision, and washing out the peri-
tonaeum have also been practised. In the ascites of cardiac and renal disease
the cathartics are most satisfactory, particularly the bitartrate of potash, given
alone or with jalap, and the large doses of salts given an hour before breakfast
with as little water as possible. These sometimes cause rapid disappearance
of the effusion, but they are not so successful in ascites as in pleurisy with
effusion. The stronger cathartics may sometimes be necessary. The ascites
forming part of the general anasarca of Bright's disease will receive consider-
ation under another section.
SECTION VI.
DISEASES OF THE EESPIRATORT , SYSTEM.
A. DISEASES OF THE NOSE.
I. ACUTE CORYZA.
Acute catarrhal inflammation of the upper air-passages, popularly known
as a " catarrh " or a " cold/' is usually an independent affection, but may pre-
cede the development of another disease.
Etiology. — Prevailing most extensively in the changeable vs^eather of the
spring and early winter, it may occur in epidemic form, many cases arising
in a community within a few weeks, outbreaks which are very like, though
less intense than the epidemic influenza. A special organism. Micrococcus
catarrlialis, has been described. Irritating fumes, such as those of iodine or
ammonia, also may cause an acute catarrh of the nose.
Symptoms. — The patient feels indisposed, perhaps chilly, has slight head-
ache, and sneezes frequently. In severe cases there are pains in the back and
limbs. There is usually slight fever, the temperature rising to 101°. The
pulse is quick, the skin is dry, and there are all the features of a feverish attack.
At first the mucous membrane of the nose is swollen, " stuffed up," and the
patient has to breathe through the mouth. A thin, clear, irritating secretion
flows, and makes the edges of the nostrils sore. The mucous membrane of
the tear-ducts is swollen, so that the eyes weep and the conjunctivae are in-
jected. The sense of smell and, in part, the sense of taste is lost. With the
nasal catarrh there is slight soreness of the throat and stiffness of the neck;
the pharynx looks red and swollen, and sometimes the act of swallowing is
painful. The larynx also may be involved, and the voice becomes husky or is
even lost. If the inflammation extends to the Eustachian tubes the hearing
may be impaired. In more severe cases there are bronchial irritation and
cough. Occasionally there is an outbreak of labial or nasal herpes. Usually
within thirty-six hours the nasal secretion becomes turbid and more profuse,
the swelling of the mucosa subsides, the patient gradually becomes able to
breathe through the nostrils, and within four or five days the symptoms dis-
appear, with the exception of the increased discharge from the nose and upper
pharynx. There are rarely any bad effects from a simple coryza. When the
attacks are frequently repeated the disease may become chronic.
The diagnosis is always easy, but caution must be exercised lest the initial
catarrh of measles or severe influenza should be mistaken for the simple coryza.
39 593
594 DISEASES OF THE RESPIRATORY SYSTEM.
Treatment. — Many cases are so mild that the patients are able to be about
and to attend to their work. If there are fever and constitutional disturbance,
the patient should be kept in bed and should take a simple fever mixture,
and at night a drink of hot lemonade and a full dose of Dover's powder.
Many persons find great benefit from the Turkish bath. For the distressing
sense of tightness and pain over the frontal sinuses, cocaine is very useful
and sometimes gives immediate relief. The 4-per-cent solution may be in-
jected into the nostrils, or cotton-wool soaked in it may be inserted into them.
Later, the snuif recommended by Ferrier is advantageous, composed, as it is,
of morphia (gr. ij), bismuth (3 iv), acacia powder (3 ij). This may occasion-
ally be blown or snuif ed into the nostrils. The fluid extract of hamamelis,
" snuffed " from the hand every two or three hours, is much better.
II. AUTUMNAL CATARRH (Hay Fever).
Definition. — An affection of the upper air-passages, often associated with
asthmatic attacks, due to the action of the pollen of certain grasses and plants
upon a hypersensitive mucous membrane.
Etiology. — This affection was first described in 1819 by Bostock, who called
it catarrhus cestivus. Morrill Wyman, of Cambridge, Mass., wrote a mono-
graph on the subject, and described two forms, the " June cold," or " rose
cold," which comes on in the spring, and the autumnal form which, in the
United States, comes on in August and September, and never persists after a
severe frost. In the Southern States cases occur all through the year. It is
more common in America and in Great Britain than on the Continent. The
disposition to the disease is hereditary. Women are more subject to it than men.
Young and middle-aged persons are most often attacked. The tendency les-
sens as age advances, though there are statements to the contrary. Dwellers
in cities are chiefly attacked. The educated and highly nervous are more sus-
ceptible. The disease affects certain families, and Beard found an hereditary
factor in 33 per cent of his cases. A morbid sensitiveness of the nasal mucosa
is present in many cases.
The disease must be differentiated from nervous coryza (which has been
induced by suggestion) and from the attacks of irritation of the nasal, con-
junctival, and bronchial mucous membranes excited by the odor of a horse,
or of the " harmless necessary cat."
Dunbar's researches have placed the etiology of the disease on a scientific
basis. He has shown that there is but one cause, the pollen of grasses and
certain plants. The pollen of about 130 different plants has now been exam-
ined, of which that of 25 grasses and of only 7 other kinds of plants exert a
definite action. The pollen of rye is the most active. Dunbar and his stu-
dents have found that the severity of hay-fever attacks is in direct proportion
to the quantity of pollen present in the atmosphere. In persons predisposed
to the disease the pollen applied to the conjunctivae or nasal mucosa excites
characteristic attacks. He has isolated a peculiar poison of an albuminous
nature from the pollen. It is so powerful that .000025 milligrammes excites
irritation in the conjunctiva of a susceptible subject. This is the amount of
toxin which corresponds to two or three pollen grains. It is entirely without
influence on normal persons. In larger doses severer attacks are caused, and,
DISEASES OF THE NOSE. 595
injected subcutaneously, it has been followed by very unpleasant symptoms.
He has succeeded in obtaining an antitoxin by injecting the poison into ani-
mals. It is capable of cutting short attacks of ordinary hay fever.
Symptoms. — These are, in a majority of the cases, very like those of ordi-
nary coryza. There may, however, be much more headache and distress, and
some patients become very low-spirited. At the outset, or even daily through-
out the attack, sneezing may be frequent. Cough is a common symptom and
may be very distressing. Paroxysms of asthma may occur indistinguishable
from the ordinary bronchial form. The two conditions may indeed alternate,
the patient having at one time an attack of common hay fever and at another,
under similar circumstances, an attack of bronchial asthma.
Treatment. — This may be comprised under four heads : First, remedies
may be given to improve the stability of the nervous system — such as
arsenic, phosphorus, and strychnia. Secondly, climatic. Dwellers in the
cities of the Atlantic seaboard and of the Central States enjoy complete
immunity in the Adirondacks and White Mountains. As a rule the disease is
aggravated by residence in agricultural districts. The dry mountain air is
unquestionably the best; there is no general rule, and there are cases which
do well at the seaside. Thirdly, the thorough local treatment of the nose, par-
ticularly the destruction of the vessels and sinuses over the sensitive areas.
Fourthly, the antitoxin treatment of Dunbar in suitable cases gives excellent
results. Owing to the peculiar nature of the disease and the constant reinfec-
tion of the mucous membranes by pollen on exposure to the outside air, it is
advised to sleep with the windows closed and to apply the serum in the morn-
ing before rising both to eyes and nose, and again during the day if the
slightest irritation is felt in the conjunctiva or nasal mucous membranes
(E. A. Glegg). The Pollantin of Dunbar is now "on the market."
III. EPISTAXIS.
Etiology. — Bleeding from the nose may result from local or constitutional
conditions. Among local causes may be mentioned traumatism, small ulcers,
picking or scratching the nose, new growths, and the presence of foreign bodies.
In chronic nasal catarrh bleeding is not infrequent. The blood may come
from one or both nostrils. The flow may be profuse after an injury.
Among general conditions with which nose-bleeding is associated, the fol-
lowing are the most important: It occurs in growing children, particularly
about the age of puberty ; more frequently in the delicate and in the rheumatic
than in the strong and vigorous. There is a family form in which many mem-
bers in several generations are affected. There is a chronic recurring epistaxis
associated with multiple telangiectasis of the skin and mucous membranes
{Quarterly Journal of Medicine, Vol. I).
Epistaxis is a very common event in persons of so-called plethoric habit.
It is stated sometimes to precede, or to indicate a liability to, apoplexy. In
venous engorgement epistaxis is not common and there may be a most extreme
grade of cyanosis without its occurrence. It is frequent in cirrhosis hepatis.
In balloon and mountain ascensions, in the very rarefied atmosphere, haemor-
rhage from the nose is a common event. In hsemophilia the nose ranks first
of the mucous membranes from which bleeding arises. It occurs in all forms of
596 DISEASES OF THE RESPIRATORY SYSTEM.
chronic anaemias, in chronic interstitial nephritis, and in cirrhosis of the liver.
It precedes the onset of certain fevers, more particularly typhoid, with which
it seems associated in a special manner. Vicarious epistaxis has been described
in cases of suppression of the menses. Lastly, it is said to be brought on by
certain psychical impressions, but the observations on this point are not trust-
worthy. The blood in epistaxis results from capillary oozing or diapedesis.
The mucous membrane is deeply congested and there are often capillary angi-
omata situated usually in the respiratory portion of the nostril and upon the
cartilaginous septum.
Symptoms. — Slight haemorrhage is not associated with any special fea-
tures. When the bleeding is protracted the patients have the more serious
manifestations of loss of blood. In the slow dripping which takes place in
some instances of haemophilia, there may be formed a remarkable blood tumor
projecting from one nostril and extending even below the mouth.
Death from ordinary epistaxis is very rare. The more blood is lost, the
greater is the tendency to clotting with spontaneous cessation of the bleeding.
Diagnosis. — The diagnosis is usually easy. One point only need be men-
tioned ; namely, that bleeding from the posterior nares occasionally occurs dur-
ing sleep and the blood trickles into the pharynx and may be swallowed. If
vomited, it may be confounded with haematemesis ; or, if coughed up, with
haemoptysis.
Treatment. — In a majority of the cases the bleeding ceases of itself. Vari-
ous simple measures may be employed, such as holding the arms above the
head, the application of ice to the nose, or the injection of cold or hot water
into the nostrils. Astringents, such as zinc, alum, or tannin, may be used;
and the tincture of the perchloride of iron, diluted with ice-water, may be
introduced into the nostrils. If the bleeding comes from an ulcerated surface,
an attempt should be made to apply chromic acid or the cautery. If the bleed-
ing is at all severe and obstinate, the posterior nares should be plugged. One
of the patients with epistaxis and spider angiomata of the skin and mucous
membranes used a finger of a rubber glove with a small rubber tube and stop-
cock by which he could dilate the glove finger, inserted into the nostril, and
so effectually control the bleeding. The inhalation of carbonic-acid gas may be
tried or a solution of gelatine or of adrenalin injected into the nostril.
B. DISEASES OF THE LARYNX.
I. ACUTE CATARRHAL LARYNGITIS.
This may come on as an independent affection or in association with gen-
eral catarrh of the upper respiratory passages.
Etiology. — Many cases are due to catching cold or to overuse of the voice ;
others come on in consequence of the inhalation of irritating gases. It may
occur in the general catarrh associated with influenza and measles. Very severe
laryngitis is excited by traumatism, either injuries from without or the lodg-
ment of foreign bodies. It may be caused by the action of very hot liquids
or corrosive poisons.
Symptoms. — There is a sense of tickling referred to the lar}aix; the cold
air irritates and, owing to the increased sensibility of the mucous membrane.
DISEASES OF THE LARYNX. 597
the act of inspiration may be painful. There is a dry cough, and the voice is
altered. At first it is simply husky, but soon phonation becomes painful, and
finally the voice may be completely lost. In adults the respirations are not
increased in frequency, but in children dyspnoea is not uncommon and may
occur in spasmodic attacks and become urgent if there is much oedema with
the inflammatory swelling.
The laryngoscope shows a swollen mucous membrane of the larynx, par-
ticularly the ary-epiglottidean folds. The vocal cords have lost their smooth
and shining appearance and are reddened and swollen. Their mobility also
is greatly impaired, owing to the infiltration of the adjoining mucous mem-
brane and of the muscles. A slight mucoid exudation covers the parts. The
constitutional symptoms are not severe. There is rarely much fever, and in
many cases the patient is not seriously ill. Occasionally cases come on with
greater intensity, the cough is very distressing, deglutition is painful, and there
may be urgent dyspnoea.
Diagnosis. — There is rarely any difficulty in determining the nature of a
case if a satisfactory laryngoscopic examination can be made. The severer
forms may simulate oedema of the glottis. When the loss of voice is marked,
the case may be mistaken for one of nervous aphonia, but the laryngoscope
would decide the question at once. Much more difficult is the diagnosis of
acute laryngitis in children, particularly in the very young, in whom it is so
hard to make a proper examination. From ordinary laryngismus it is to be
distinguished by the presence of fever, the mode of onset, and particularly the
coryza and the previous symptoms of hoarseness or loss of voice. Membranous
laryngitis may at first be quite impossible to differentiate, but in a majority
of cases of this affection there are patches on the pharynx and early swelling of
the cervical glands. The symptoms, too, are much more severe.
Treatment. — Rest of the larynx should be enjoined, so far as phonation is
concerned. In cases of any severity the patient should be kept in bed. The
room should be at an even temperature and the air saturated with moisture.
Early in the disease, if there is much fever, aconite and citrate of potash may
be given, and for the irritating painful cough a full dose of Dover's powder
at night. An ice-bag externally often gives great relief.
II. CHRONIC LARYNGITIS.
Etiology. — The cases usually follow repeated acute attacks. The most com-
mon causes are overuse of the voice, particularly in persons whose occupation
necessitates shouting in the open air. The constant inhalation of irritating
substances, as tobacco-smoke, may also cause it.
Symptoms. — The voice is usually hoarse and rough and in severe cases may
be almost lost. There is usually very little pain ; only the unpleasant sense of
tickling in the larynx, which causes a frequent desire to cough. With the
laryngoscope the mucous membrane looks swollen, but much less red than in
the acute condition. In association with the granular pharyngitis, the mucous
glands of the epiglottis and of the ventricles may be involved.
Treatment. — The nostrils should be carefully examined, since in some
instances chronic laryngitis is associated with and even dependent upon ob-
struction to the free passage of air through the nose. Local application must
598 DISEASES OF THE RESPIRATORY SYSTEM.
be made directly to the larjoix, either with a brush or by means of a spray.
Among the remedies most recommended are the solutions of nitrate of silver,
elilorate of potash, perchloride of zinc, and tannic acid. Insufflations of bis-
muth are sometimes useful.
Among directions to be given are the avoidance of heated rooms and loud
speaking, and abstinence from tobacco and alcohol. The throat should not be
too much muffled, and morning and evening the neck should be sponged with
cold water„
III. CE3DEMAT0TJS LARYNGITIS.
Etiology. — CEdema of the glottis, or, more correctly, of the structures
which form the glottis, a very serious affection, is met with (a) as a rare
sequence of ordinary acute laryngitis; (&) in chronic diseases of the larynx,
as syphilis or tubercle; (c) in severe inflammatory diseases like diphtheria, in
.erysipelas of the neck, and in various forms of cellulitis; (d) occasionally
in the acute infectious diseases — scarlet fever, typhus, or typhoid ; in Bright's
disease, either acute or chronic, there may be a rapidly developing oedema;
(e) in angio-neurotic oedema.
Symptoms. — There is dyspnoea, increasing in intensity, so that within an
hour or two the condition becomes very critical. There is sometimes marked
stridor in respiration. The voice becomes husky and disappears. The laryn-
goscope shows enormous swelling of the epiglottis, which can sometimes be
felt with the finger or even seen when the tongue is strongly depressed with a
spatula. The arj'^-epiglottidean folds are the seat of the chief swelling and
may almost meet in the middle line. Occasionally the oedema is below the
true cords.
The diagnosis is rarely difficult, inasmuch as even without the laryngo-
scope the swollen epiglottis can be seen or felt with the finger. The condition
is very fatal.
Treatment. — An ice-bag should be placed on the larynx, and the patient
given ice to suck. If the symptoms are urgent, the throat should be sprayed
with a strong solution of cocaine, and the swollen epiglottis scarified. If
relief does not follow, tracheotomy should immediately be performed. The
high rate of mortality is due to the fact that this operation is as a rule too
long delayed.
IV. SPASMODIC LARYNGITIS (Laryngismus stridulus).
Spasm of the glottis is met with in many affections of the larynx, but there
is a special disease in children which has received the above-mentioned and
other names.
Etiology. — A purely nervous affection, without any inflammatory condi-
tion of the larynx, it occurs in children between the ages of six months and
three years, and is most commonly seen in connection with rickets. As
Escherich has shown, the disease has close relations with tetany and may
display many of the accessory phenomena of this disease. Often the attack
comes on when the child has been crossed or scolded. Mothers sometimes call
the attacks ^^ passion fits" or attacks of "holding the breath." It was sup-
DISEASES OF THE LARYNX. 599
posed at one time that they were associated with enlargement of the thymus,
and the condition therefore received the name of thymic asthma.
The actual state of the larynx during a paroxysm is a spasm of the
adductors, but the precise nature of the influences causing it is not yet known,
whether centric or reflex from peripheral irritation. The disease is not so
common in America as in England.
Symptoms. — The attacks may come on either in the night or in the day;
often just as the child awakes. There is no cough, no hoarseness, but the
respiration is arrested and the child struggles for breath, the face gets con-
gested, and then, with a sudden relaxation of the spasm, the air is drawn into
the lungs with a high-pitched crowing sound, which has given to the afl ection
the name of " child-crowing." Convulsions may occur during an attack or
there may be carpo-pedal spasms. Death may, but rarely does, occur during
the attack. With the cyanosis the spasm relaxes and respiration begins. The
attacks may recur with great frequency throughout the day.
Treatment. — The gums should be carefully examined and, if swollen and
hot, freely lanced. The bowels should be carefully regulated, and as these
children are usually delicate or rickety, nourishing diet and cod-liver oil
should be given. By far the most satisfactory method of treatment is the cold
sponging. In severe cases, two or three times a day the child should be placed
in a warm bath, and the back and chest thoroughly sponged for a minute or
two with cold water. Since learning this practice from Einger, at the Uni-
versity Hospital, London, I have seen many cases in which it proved success-
ful. It may be employed when the child is in a paroxysm, though if the
attack is severe and the lividity is great it is much better to dash cold water
into the face. Sometimes the introduction of the finger far back into the
throat will relieve the spasm.
Spasmodic croup, believed to be a functional spasm of the muscles of the
larynx, is an affection seen most commonly between the ages of two and five
years. According to Trousseau's description, the child goes to bed well, and
about midnight or in the early morning hours awakes with oppressed breath-
ing, harsh, croupy cough, and perhaps some huskiness of voice. The oppres-
sion and distress for a time are very serious, the face is congested, and there
are signs of approaching cyanosis. The attack passes off abruptly, the child
falls asleep and awakes the next morning feeling perfectly well. These attacks
may be repeated for several nights in succession, and usually cause great alarm
to the parents. Whether this is entirely a functional spasm is, I think, doubt-
ful. There are instances in which the child is somewhat hoarse throughout
the day, and has slight catarrhal symptoms and a brazen, croupy cough. There
is probably slight catarrhal laryngitis with it. These cases are not infrequently
mistaken for true croup, and parents are sometimes unnecessarily disturbed
by the serious view which the physician takes of the case. Too often the poor
child, deluged with drugs, is longer in recovering from the treatment than he
would be from the disease. To allay the spasm a whiff of chloroform may be
administered, which will in a few moments give relief, or the child may be
placed in a hot bath. A prompt emetic, such as zinc or wine of ipecac, will
usually relieve the spasm, and is specially indicated if the child has overloaded
the stomach through the day.
600 DISEASES OF THE RESPIRATORY SYSTEM.
V. TUBERCULOUS LARYNGITIS.
Etiology. — Tubercles may arise primarily in the laryngeal mucosa, but in
the great majority of cases the afEection is secondary to pulmonary tubercu-
losis, in which it is met with in a variable proportion of from 18 to 30 per
cent. Laryngitis may occur very early in pulmonary tuberculosis. There
may be well-marked involvement of the larynx with signs of very limited
trouble at one apex. These are cases which, in my experience, run a very
unfavorable course.
Morbid Anatomy. — The mucosa is at first swollen ^nd presents scattered
tubercles, which seem to begin in the neighborhood of the blood-vessels. By
their fusion small tuberculous masses arise, which caseate and finally ulcerate,
leaving shallow irregular losses of substance. The ulcers are usually covered
with a grayish exudation, and there is a general thickening of the mucosa
about them, which is particularly marked upon the arytenoids. The ulcers
may erode the true cords and finally destroy them, and passing deeply may
cause perichondritis with necrosis and occasionally exfoliation of the carti-
lages. The disease may extend laterally and involve the pharynx, and down-
ward over the mucous membrane, covering the cricoid cartilage toward the
oesophagus. Above, it may reach the posterior wall of the pharynx, and in
rare cases extend to the fauces and tonsils. The epiglottis may be entirely
destroyed. There are rare instances in which cicatricial changes go on to such
a degree that stenosis of the larynx is induced.
Symptoms. — The first indication is slight huskiness of the voice, which
finally deepens to hoarseness, and in advanced stages there may be complete
loss of voice. There is something very suggestive in the early hoarseness of
tuberculous laryngitis. The attention may be directed to the lungs simply by
the quality of the voice.
The cough is in part due to involvement of the larynx. Early in the
disease it is not very troublesome, but when the ulceration is extensive it
becomes husky and ineffectual. Of the symptoms, none is more aggravating
than the dysphagia, which is met with particularly when the epiglottis is
involved, and when the ulceration has extended to the pharynx. There is no
more distressing or painful complication in phthisis. In instances in which
the epiglottis is in great part destroyed, with each attempt to take food there
are distressing paroxysms of cough, and even of suffocation.
With the laryngoscope there is seen early in the disease a pallor of the
mucous membrane, which also looks thickened and infiltrated, particularly
that covering the arytenoid cartilages. The ulcers are very characteristic.
They are broad and shallow, with gray bases and ill-defined outlines. The
vocal cords are infiltrated and thickened, and ulceration is very common.
The diagnosis is rarely difficult, as it is usually associated with well-marked
pulmonary disease. In case of doubt the secretion from the base of an ulcer
should be examined for bacilli.
Treatment.— The voice should not be used. The ulcers should be sprayed
and kept thorouglily cleansed with a solution of tannic acid, nitrate of silver,
or sulphate of zinc. The insufflation, three times a day, of a powder of iodo-
form with morphia, after cleansing the ulcers with a spray, relieves the pain
DISEASES OF THE LARYNX. 601
in a majority of the cases. Cocaine (4-per-cent solution) applied with the
atomizer will often enable the patient to swallow his food comfortably. There
are, however, distressing cases of extensive laryngeal and pharyngeal ulcera-
tion in which even cocaine loses its good effects. When the epiglottis is lost
the difficulty in swallowing becomes very great. Wolfenden states that this
may be obviated if the patient hangs his head over the side of the bed and
sucks milk through a rubber tube from a mug placed on the floor.
VI. SYPHILITIC LARYNGITIS.
Syphilis attacks the larynx with great frequency. It may result from
the inherited disease or be a secondary or tertiary manifestation of the ac-
quired form.
Symptoms. — In secondary syphilis there is occasionally erythema of the
larynx, Avhich may go on to definite catarrh, but has nothing characteristic.
The process may proceed to the formation of superficial whitish ulcers, usually
symmetrically placed on the cords or ventricular bands. Mucous patches and
condylomata are rarely seen. The symptoms are practically those of slight
loss of voice with laryngeal irritation, as in the simple catarrhal form.
The tertiary larjoigeal lesions are numerous and very serious. True gum-
mata, varying in size from the head of a pin to a small nut, arise in the sub-
mucous tissue, most commonly at the base of the epiglottis. They go through
the changes characteristic of these structures and may either break down, pro-
ducing extensive and deep ulceration, or — and this is more characteristic of
syphilitic laryngitis — in their healing form a fibrous tissue which shrinks and
produces stenosis. The ulceration is apt to extend deeply and involve the carti-
lage, inducing necrosis and exfoliation, and even haemorrhage from erosion
of the arteries. OEdema may suddenly prove fatal. The cicatrices which fol-
low the sclerosis of the gummata or the healing of the ulcers produce great
deformity. The epiglottis, for instance, may be tied down to the pharyngeal
wall or to the epiglottic folds, or even to the tongue; and eventually a stenosis
results, which may necessitate tracheotomy.
The laryngeal symptoms of inherited syphilis have the usual course of
these lesions and appear either early, within the first five or six months, or
after puberty; most commonly in the former period. Of 76 cases, J. N.
Mackenzie found that 63 occurred within the first year. The gummatous infil-
tration leads to ulceration, most commonly of the epiglottis and in the ven-
tricles, and the process may extend deeply and involve the cartilage. Cica-
tricial contraction may also occur.
The diagnosis of syphilis of the larynx is rarely difficult, since it occurs
most commonly in connection with other symptoms of the disease.
Treatment. — The administration of constitutional remedies is the most
important, and under mercury and iodide of potassium the local symptoms
may rapidly be relieved. The tertiary laryngeal manifestations are always
serious and difficult to treat. The deep ulceration is specially hard to combat,
and the cicatrization may necessitate tracheotomy, or the gradual dilatation,
as practised bv Schroetter.
40 "
602 DISEASES OF THE RESPIRATORY SYSTEM.
C. DISEASES OE THE BRONCHI.
I. ACUTE BRONCHITIS.
Acute catarrhal inflammation of the bronchial mucous membrane is a very
common disease, rarely serious in healthy adults, but very fatal in the old and
in the young, owing to associated pulmonary complications. It is bilateral
and affects either the larger and medium sized tubes or the smaller bronchi,
in which case it is known as capillary bronchitis.
We shall speak only of the former, as the latter is part and parcel of
broncho-pneumonia.
Etiology. — Acute bronchitis is a common sequel of catching cold, and is
often nothing more than the extension downward of an ordinary coryza. It
occurs most frequently in the changeable weather of early spring and late
autumn. Its association with cold is well indicated by the popular expression
" cold on the chest." It may prevail as an epidemic apart from influenza, of
which it is an important feature.
Acute bronchitis is associated with many other affections, notably measles.
It is by no means rare at the onset of t^^phoid fever and malaria. It is present
also in asthma and whooping-cough. The subjects of spinal curvature are
specially liable to the disease. The bronchitis of Bright's disease, gout, and
heart-disease is usually a chronic form. It attacks persons of all ages, but
most frequently the young and the old. There are individuals who have a
special disposition to bronchial catarrh, and the slightest exposure is apt to
bring on an attack. Persons who live an out-of-door life are usually less sub-
ject to the disease than those who follow sedentary occupations.
The affection is probably microbic, though we have as yet no definite evi-
dence upon this point.
Morbid Anatomy. — The mucous membrane of the trachea and bronchi is
reddened, congested, and covered with mucus and muco-pus, which may be
seen oozing from the smaller bronchi, some of which are dilated. The finer
changes in the mucosa consist in desquamation of the ciliated epithelium,
swelling and cedema of the submucosa, and infiltration of the tissue with leu-
cocytes. The mucous glands are much swollen.
Symptoms. — The symptoms of an ordinary " cold " accompany the onset
of an acute bronchitis. The coryza extends to the tubes, and may also affect
the lar}-nx. producing hoarseness, which in many cases is marked. A chill is
rare, but there is invariably a sense of oppression, with heaviness and languor
and pains in the bones and back. In mild cases there is scarcely any fever,
but in severer forms the range is from 101° to 103°. The bronchial symptoms
set in with a feeling of tightness and rawness beneath the sternum and a
sansation of oppression in the chest. The cough is rough at first, and often
of a ringing character. It comes on in paroxysms which rack and distress
the patient extremely. During the severe spells the pain may be very intense
beneath the sternum and along the attachments of the diaphragm. At first
the cough is dry and the expectoration scanty and viscid, but in a few days
the secretion becomes muco-purulent and abundant, and finally purulent.
With the loosening of the cough great relief is experienced. The sputum is
DISEASES OF THE BRONCHI. 603
made up largely of pus-cells, with a variable number of the large round
alveolar cells, many of which contain carbon grains, while others have under-
gone the myelin degeneration.
Physical Signs. — The respiratory movements are not greatly increased
in frequency unless the fever is high. There are instances, however, in which
the breathing is rapid and when the smaller tubes are involved there is
dyspncBa. On palpation the bronchial fremitus may often be felt. On aus-
cultation in the early stage, piping sibilant rales are everywhere to be heard.
They are very changeable, and appear and disappear with coughing. With
the relaxation of the bronchial membranes and the greater abundance of the
secretion, the rales change and become mucous and bubbling in quality. The
bases of the lungs should be carefully examined each day, particularly in
children and the aged.
Course. — The course of the disease depends on the conditions under which
it arises. In healthy adults, by the end of a week the fever subsides and the
cough loosens. In another week or ten days convalescence is fully established.
In young children the chief risk is in the extension of the process downward.
In measles and whooping-cough, the ordinary bronchial catarrh is very apt to
descend to the finer tubes, which become dilated and plugged with muco-pus,
inducing areas of collapse, and finally broncho-pneumonia. This extension
is indicated by changes in the physical signs. Usually at the base the rales
are subcrepitant and numerous and there may be areas of defective resonance
and of feeble or distant tubular breathing. In the aged and debilitated there
are similar dangers if the process extends from the larger to the smaller tubes.
In old age the bronchial mucosa is less capable of expelling the mucus, which
is more apt to sag to the dependent parts and induce dilatation of the tubes
with extension of the inflammation to the contiguous air-cells.
Diagnosis. — The diagnosis of acute bronchitis is rarely difficult. Although
the mode of onset may be brusque and perhaps simulate pneumonia, yet the
absence of dulness and blowing breathing, and the general character of the
bronchial inflammation, render the diagnosis easy. About once a year I see
a case of typhoid fever, in which the diagnosis at first has been acute bron-
chitis. The complication of broncho-pneumonia is indicated by the greater
severity of the symptoms, particularly the dyspnoea, the changed color, and
the physical signs.
Treatment. — In mild cases, household measures suffice. The hot foot-
bath, or the warm bath, a drink of hot lemonade, and a mustard plaster on the
chest will often give relief. For the dry, racking cough, the symptom most
complained of by the patient, Dover's powder is the best remedy. It is a
popular belief that quinine, in full doses, will check an oncoming cold on the
chest, but this is doubtful. It is a common custom when persons feel the
approach of a cold to take a Turkish bath, and though the tightness and
oppression may be relieved by it, there is in a majority of the cases great risk.
Some of the severest cases of bronchitis which I have seen have followed this
initial Turkish bath. No doubt, if the person could go to bed directly from
the bath, its action would be beneficial, but there is great risk of catching
" cold " in going home from the bath. Relief is obtained from the unpleasant
sense of rawness by keeping the air of the room saturated with moisture, and
in this dry stage the old-fashioned mixture of the wines of antimony and
604 DISEASES OF THE RESPIRATORY SYSTEM.
ipecacuanha with liquor ammonii acetatis and nitrous ether is useful. If the
pulse is very rapid, tincture of aconite may be given, particularly in the case
of children. For the cough, when dry and irritating, opium should be freely
used in the form of Dover's powder or paregoric. Of course, in the very
young and the aged care must be exercised in the use of opium, particularly
if the secretions are free ; but for the distressing, irritative cough, which keeps
the patient awake, opium in some form gives the only relief. As the cough
loosens and the expectoration is more abundant, the patient becomes more
comfortable. In this stage it is customary to ply him with expectorants of
various sorts. Though useful occasionally, they should not be given as a
matter of routine. A mixture of squills, ammonia, and senega is a favorite
one with many practitioners at this stage.
In the acute bronchitis of children, if the amount of secretion is large
and difficult to expectorate, or if there is dyspnoea and the color begins to
get dusky, an emetic (a tablespoonful of ipecac wine) shoxdd be given at once
and repeated if necessary.
II. CHRONIC BRONCHITIS.
Etiology. — This affection may follow repeated attacks of acute bronchitis,
but it is most commonly met with in chronic lung affections, heart-disease,
aneurism of the aorta, gout, and renal disease. It is frequent in the aged;
the young rarely are affected. Climate and season have an important influence.
It is the winter cough of the aged, recurring with regularity as the weather
gets cold and changeable. Owing to" the more uniform heating of the houses, it
is much less common in Canada and in the United States than in England.
Morbid Anatomy. — The bronchial mucosa presents a great variety of
changes, depending somewhat upon the disease with which chronic bronchitis
is associated. In some cases the mucous membrane is very thin, so that the
longitudinal bands of elastic tissue stand out prominently. The tubes are
dilated, the muscular and glandular tissues are atrophied, and the epithelium
is in great part shed.
In other instances the mucosa is thickened, granular, and infiltrated.
There may be ulceration, particularly of the mucous follicles. Bronchial dila-
tations are not uncommon and emphysema is a constant accompaniment.
Symptoms. — In the form met with in old men, associated with emphysema,
gout, or heart-disease, the chief symptoms are as follows : Shortness of breath,
which may not be noticeable except on exertion. The patients " puff and
blow " on going up hill or up a flight of stairs. This is due not so much to
the chronic bronchitis itself as to associated emphysema or even to cardiac
weakness. They complain of no pain. The cough is variable, changing with
the weather and with the season. During the summer they may remain free,
but each succeeding winter the cough comes on with severity and persists.
There may be only a spell in the morning, or the chief distress is at night.
The sputum in chronic bronchitis is very variable. In cases of the so-called
dry catarrh there is no expectoration. Usually, however, it is abundant, muco-
purulent, or distinctly purulent in character. There are instances in which
the patient coughs up for years a thin fluid sputum. There is rarely fever.
The general health may be good and the disease may present no serious fea-
DISEASES OF THE BRONCHI. 605
tures apart from the liability to induce emphysema and bronchiectasy. In
many cases it is an incurable affection. Patients improve and the cough dis-
appears in the summer time only to return during the winter months.
Physical Signs. — The chest is usually distended, the movements are
limited, and the condition is often that which we see in emphysema. The
percussion note is clear or hyperresonant. On auscultation, expiration is pro-
longed and wheezy and rhonchi of various sorts are heard — some high-pitched
and piping, others deep-toned and snoring. Crepitant rales are common at
the bases.
Clinical Varieties. — The description just given is of the ordinary chronic
bronchitis which occurs in connection with emphysema and heart-disease and
in many elderly men. There are certain forms which merit special descrip-
tion: (a) There is a form of chkonic bronchitis in women, which comes
on between the ages of twenty and thirty and may continue indefinitely with-
out serious impairment of the health. In several cases the cough followed
influenza, and there may be slight bronchiectasis.
(&) Bronchorrhcea. — Excessive bronchial secretion is met with under
several conditions. It must not be mistaken for the profuse expectoration of
bronchiectasis. The secretion may be very liquid and watery — hroncJiorrhoea
serosa, and in extraordinary amount. More commonly, it is purulent though
thin, and with greenish or yellow-green masses. It may be thick and uniform.
This profuse bronchial secretion is usually a manifestation of chronic bron-
chitis, and may lead to dilatation of the tubes and ultimately to fetid
bronchitis. In the young the condition may persist for years without impair-
ment of health and without apparently damaging the lungs.
(c) Putrid Bronchitis. — Fetid expectoration is met with in connection
with bronchiectasis, gangrene, abscess, or with decomposition of secretions
within phthisical cavities and in an empyema which has perforated the
lung. There are instances in which, apart from any of these states, the
expectoration has a fetid character. The sputa are abundant, usually thin,
grayish-white in color, and they separate into an upper fluid layer capped
with frothy mucus and a thick sediment in which may sometimes be found
dirty yellow masses the size of peas or beans — the so-called Dittriclis plugs.
The affection is very rare apart from the above-mentioned conditions. In
severe cases it leads to changes in the bronchial walls, pneumonia, and often
to abscess or gangrene. Metastatic brain abscess has followed putrid bron-
chitis in a certain number of cases.
{d) Dry Catarrh. — The catarrhe sec of Laennec, a not uncommon form,
is characterized by paroxysms of coughing of great intensity, with little or
no expectoration. It is usually met with in elderly persons with emphysema,
and is one of the most obstinate of all varieties of bronchitis.
Treatment. — Eemoval to a southern latitude may prevent the onset. In
England the milder climate of Falmouth, Torquay, and Bournemouth is
suitable for those who cannot go elsewhere. Egypt, southern France, southern
California, and Florida furnish winter climates in which the subjects of
chronic bronchitis live with the greatest comfort. With care chronic bron-
chitis may prove to be the slight ailment that, as Oliver Wendell Holmes says,
promotes longevity.
The first endeavor is to ascertain, if possible, whether there are constitu-
606 DISEASES OF THE RESPIRATORY SYSTEAi.
tional or local affections with which it is associated. In many instances the
urine is found to be highly acid, perhaps slightly albuminous, and the arteries
are stiff. In the form associated with this condition, sometimes called gouty
bronchitis, the attacks seem related to the defective renal elimination, and to
this condition the treatment should be first directed. In other instances there
are heart-disease and emphysema. In the form occurring in old men much
may be done in the way of prophjdaxis. There is no doubt that with prudence
even in the most changeable winter weather much may be done to prevent
the onset of chronic bronchitis. Woollen undergarments should be used and
especial care should be taken in the spring months not to change them for
lighter ones before the warm weather is established.
Cure is seldom affected by medicinal remedies. There are instances in
which iodide of potassium acts with remarkable benefit, and it should always
be given a trial in cases of paroxysmal bronchitis of obscure. origin. For the
morning cough, bicarbonate of sodium (gr. xv), chloride of sodium (gr. v),
spirits of chloroform (fflv) in anise water and taken with an equal amount
of warm water will be found useful (Fowler). When there is much sense
of tightness and fulness of the chest, the portable Turkish bath may be tried.
When, the secretion is excessive muriate of ammonia and senega are useful.
Stimulating expectorants are contraindicated. When the heart is feeble, the
combination of digitalis and strychnia is very beneficial. Turpentine, the old-
fashioned remedy so warmly recommended by the Dublin physicians, has in
many quarters fallen undeservedly into disuse. Preparations of tar, creosote,
and terebene are sometimes useful. Of other balsamic remedies, sandal-wood,
the compound tincture of benzoin, copaiba, balsam of Peru or tolu may be
used. Inhalations of eucah^tus and of the spray of ipecacuanha wine are
often very useful. If fetor be present, carbolic acid in the form of spray (10
to 20 per cent solution) will lessen the odor, or thymol (1 to 1,000), but the
intratracheal medication is the most efficient. After the larjmx is ansesthe-
tized with a 4 per cent cocaine solution, inject with suitable syringe about
two drachms of olive oil, vsdth gr. ^ of iodoform, and gr. ^ of morphia if there
is irritating cough. For urgent dyspnoea with cyanosis, bleeding from the
arm gives most relief,
III. BRONCHIECTASIS.
Etiology. — The following excellent classification is given by Barty King:
I. Bronchiolectasis-; ^i
I Chronic
Chronic bronchitis
Broncho-pneumonic
A. Pure-( 3. Chronic pneumonic
Pneumonic
Pleuritic
B. Tuberculous
11. Bronchiectasis
C. Traumatic -
'1. Aneurism
2. Tumor
3. Foreign body
,4. Syphilis
DISEASES OF THE BRONCHI. 607
In addition there is a congenital defect which Grawitz has described as hron-
chicctasis universalis.
Unquestionably the weakening of the bronchial wall is the most impor-
tant, probably the essential, factor in inducing bronchiectasy, since the wall
is then not able to resist the pressure of air in severe spells of coughing and
in straining. In some instances the mere weight of the accumulated secretion
may be sufficient to distend the terminal tubules, as is seen in compression of a
bronchus by aneurism. Barty King lays great stress on pleural adherency as
a factor in the initial dilatation of the tubes. The disease seems to have
increased in frequency since the influenza epidemics of the past fifteen years.
Of six consecutive cases in my wards in the session of 1904-05 from every
one Boggs isolated the influenza bacillus.
Morbid Anatomy. — Two chief forms of bronchiectasis are recognized — the
cylindrical and the saccular — which may exist together in the same lung. The
condition may be general or partial. Universal bronchiectasis is always uni-
lateral. It occurs in rare congenital cases and is occasionally seen as a
sequence of interstitial pneumonia. The entire bronchial tree is represented
by a series of sacculi opening one into the other. The walls are smooth and
possibly without ulceration or erosion except in the dependent parts. The
lining membrane of the sacculi is usually smooth and glistening. The dila-
tations may form large cysts iminediately beneath the pleura. Intervening
between the sacculi is a dense cirrhotic lung tissue. The partial dilatations —
the saccular and cylindrical — are common in chronic phthisis, particularly at
the apex, in chronic pleurisy at the base, and in emphysema. Here the dila-
tation is more commonly cylindrical, sometimes fusiform. The bronchial
mucous membrane is much involved and sometimes there is a narrowing of
the lumen. Occasionally one meets with a single saccular bronchiectasy in
connection with chronic bronchitis or emphysema. Some of these look like
simple cysts, with smooth walls, without fluid contents. Bronchiolectasis as an
acute condition may follow the infectious diseases, as in the cases described by
Sharkey, Carr, and others. The chronic variety is a sequel of bronchitis in
old subjects.
Histologically the bronchi which are the seat of dilatation show important
changes. In the large, smooth dilatations the cylindrical is replaced by a
pavement epithelium. The muscular layer is stretched, atrophied, and the
fibres separated; the elastic tissue is also much stretched and separated. In
the large saccular bronchiectases and in some of the cylindrical forms, due to
retained secretions, the lining membrane is ulcerated. The contents of some
of the larger bronchiectatic cavities are horribly fetid.
Symptoms. — There are acute cases, usually the bronchiolectasis of children ;
but a recent case in my wards of the broncho-pneumonia form died in six
weeks from the onset. The bronchi of the lower lobes were dilated; there
were areas of broncho-pneumonia and one or two spots of gangrene. The
patient became hemiplegic, probably from abscess of the brain. In the
limited dilatations of phthisis, emphysema, and chronic bronchitis, the symp-
toms are in great part those of the original disease, and the condition often
is not suspected during life.
In extensive saccular bronchiectasis the characters of the cough and expec-
toration are distinctive. The patient will pass the greater part of the day
608 DISEASES OF THE RESPIRATORY SYSTEM.
without any cough and then in a severe paroxysm will bring up a large quan-
tity of sputum. Ten of my eases showed this symptom. Of 33 of my cases the
amount for twenty-four hours was, in 2 less than 100 cc, in 11 from 100-300
cc, in 2 almost 500 cc, in 7 over 600 cc. In one case with over one litre
per day the cavities found were very small. Sometimes change of the posi-
tion will bring on a violent attack, probably due to the fact that some of the
secretion flows from the dilatation to a normal tube. The daily spell of
coughing is usually in the morning. The expectoration is in many instances
very characteristic. It is grayish or grayish-brown in color, fluid, purulent,
with a peculiar acid, sometimes fetid, odor. Placed in a conical glass, it sepa-
rates into a thick granular layer below and a thin mucoid intervening layer
above, which is capped by a brownish froth. Microscopically it consists of
pus-corpuscles, often large crystals of fatty acids, which are sometimes in
enormous numbers over the field and arranged in bunches. H^matoidin
crystals are sometimes present. Elastic fibres are seldom found except when
there is ulceration of the bronchial walls. Tubercle baccilli are not present.
In some cases, as in 10 of my series, the expectoration is very fetid and has all
the characters of that described under fetid bronchitis. Nummular expectora-
tion, such as comes from phthisical cavities, is not common. Hsemorrhage
occurred in 14 out of 35 cases analyzed by Fowler, in 17 of my 24 cases,
slight in 8, and extreme in 3. Abscess of the brain has in a few instances
followed the bronchiectasis. Eheumatoid affections may occur, and it is one
of the conditions with which the pulmonary osteo-arthropathy is commonly
associated.
Diagnosis. — The diagnosis is not possible in a large number of the cases.
In the extensive sacculated forms, unilateral and associated with interstitial
pneumonia or chronic pleurisy, the diagnosis is easy. There is contraction of
the side, which in some instances is not at all extreme. The cavernous signs
may be chiefly at the base and may vary according to the condition of the
cavity, whether full or empty. There may be the most exquisite amphoric
phenomena and loud resonant rales. The condition persists for years .and is
not inconsistent with a tolerably active life. The patients frequently show
signs of marked embarrassment of the pulmonary circulation. There is cya-
nosis on exertion, the finger-tips are clubbed, and the nails incurved. A con-
dition very difficult to distinguish from bronchiectasis is a limited pleural
cavity communicating with a bronchus.
Treatment. — Medical treatment is not satisfactor}'', since it is impossible
to heal the cavities. I have practised the injection of antiseptic fluids in some
instances with benefit. Intratracheal injections have been very warmly recom-
mended of late. With a suitable syringe a drachm may be injected twice a
day of the following solution : Menthol 10 parts, guaiacol 2 parts, olive oil 88
parts. Or better still when the odor is very offensive iodoform in olive oil.
The creasote vapor bath may be given in a small room. The patient's eyes
must be protected with well-fitting goggles, and the nostrils stuffed with
cotton-wool. A drachm of creasote is poured upon water in a saucer and
vaporized by placing the saucer over a spirit lamp. At first the vapor is very
irritating and disagreeable, but the patient gets used to it. The bath should
be taken at first every other day for fifteen minutes, then gradually increased
to an hour daily. The treatment should be continued for three months. I
DISEASES OF THE BRONCHI. 609
can recommend it as a most satisfactory metliod of treatment. In suitable
cases drainage of the cavities may be attempted, particularly if the patient is in
fairly good condition. For the fetid secretion turpentine may be given, or tere-
bene, and inhalations used of carbolic acid or thymol,
IV. BRONCHIAL ASTHMA.
Asthma is a term which has been applied to various conditions associated
with dyspnoea — hence the names cardiac and renal asthma — but its use should
be limited to the affection known as bronchial or spasmodic asthma.
Etiology. — All writers agree that there is in a majority of cases of bron-
chial asthma a strong neurotic element. Many regard it as a neurosis in which,
according to one view, spasm of the bronchial muscles, according to the other
turgescence of the mucosa, results from disturbed innervation, pneumogastric
or vaso-motor. Of the numerous theories the following are the most im-
portant :
(1) That it is due to spasm of the bronchial muscles, a theory which has
perhaps the largest number of adherents. The original experiments of
C, J. B. Williams, upon which it is largely based, have been confirmed by
Brodie.
(2) That the attack is due to swelling of the bronchial mucous membrane
— fiuctionary hypersemia (Traube), vaso-motor turgescence (Weber), diffuse
hypergemic swelling (Clark).
(3) That in many cases it is a special form of inflammation of the
smaller bronchioles — hroncliiolitis exudativa (Curschmann). Other theories
which may be mentioned are that the attack depends on spasm of the dia-
phragm or on reflex spasm of all the inspiratory muscles.
As already mentioned, the so-called hay fever is an affection which has
many resemblances to bronchial asthma, with which the attacks may alter-
nate. In the suddenness of onset and in many of their features these dis-
eases have the same origin and differ only in site, as suggested by Sir Andrew
Clark and now generally acknowledged by specialists. Making due allowance
for anatomical differences, if the structural changes occurring in the nasal
mucous membrane during an attack of hay fever were to occur also in various
parts of the bronchial mucosa, their presence there would afford a complete
and adequate explanation of the facts observed during a paroxysm of bronchial
asthma (Clark). With this statement I fully agree, but the observations of
Curschmann have directed attention to a feature in asthma which has been
neglected; namely, that in a majority of the cases it is associated with an
exudation, such as might be supposed to come from a turgescent mucosa and
which is of a very characteristic and peculiar character. The hypergemia and
swelling of the mucosa and the extremely viscid, tenacious mucus explain well
the hindrance to inspiration and expiration and also the quality of the rales.
An oedema of the angio-neurotic type has been described in the hands and
arms in asthma (J. S. Billings, Jr.).
Some general facts with reference to etiology may be mentioned. The
affection sometimes runs in families, particularly those with irritable and
unstable nervous systems. The attack may be associated with neuralgia or,
as Salter mentions, even alternate with epilepsy. Men are more frequently
610 DISEASES OF THE RESPIRATORY SYSTEM.
affected than women. The disease often begins in cliildhood and sometimes
lasts until old age. It may follow an attack of whooping-cough. One of its
most striking peculiarities is the bizarre and extraordinary variety of circum-
stances which at times induce a paroxysm. Among these local conditions
climate or atmosphere are most important. A person may be free in the city
and invariably suffer from an attack when he goes into the country, or into
one special part of the coimtry. Such cases are by no means uncommon.
Breathing the air of a particular room or a dusty atmosphere may bring on
an attack. Odors, particularly of flowers and of hay, or emanations from
animals, as the horse, dog, or cat, may at once cause an outbreak. Fright or
violent emotion of any sort may bring on a paroxysm. Uterine and ovarian
troubles were formerly thought to induce attacks and may do so in rare in-
stances. Diet, too, has an important influence, and in persons subject to the
disease severe paroxysms may be induced by overloading the stomach, or by
taking certain articles of food. Chronic cases, in which the attacks recur year
after year, gradually become associated with emphysema, and every fresh
" cold " induces a paroxysm. And lastly, many cases of bronchial asthma are
associated with affections of the nose, particularly with hypertrophic rhinitis
and nasal polypi.
Briefly stated then, bronchial asthma is a neurotic affection, characterized
by hypersemia and turgescence of the mucosa of the smaller bronchial tubes
and a peculiar exudate of mucin. The attacks may be due to direct irritation
of the bronchial mucosa or may be induced reflexly, by irritation of the nasal
mucosa, and indirectly, too, by reflex influences, from stomach, intestines, or
genital organs.
Symptoms. — Premonitory sensations precede some attacks, such as chilly
feelings, a sense of tightness in the chest, flatulence, the passage of a large
quantity of urine, or great depression of spirits. Nocturnal attacks are com-
mon. After a few hours' sleep, the patient is aroused with a distressing sense
of want of breath and a feeling of great oppression in the chest. Soon the
respiratory efforts become violent, all the accessory muscles are brought into
play, and in a few minutes the patient is in a paroxysm of the most intense
dyspnoea. The face is pale, the expression anxious, speech is impossible, and
in spite of the most strenuous inspiratory efforts very little air enters the lungs.
Expiration is prolonged and also wheezy. The number of respirations, how-
ever, is not much increased. The asthmatic fit may last from a few minutes to
several hours. When severe, the signs of defective aeration soon appear, the
face becomes bedewed with sweat, the pulse is small and quick, the extremities
get cold, and just as the patient seems to be at his worst, the breathing begins
to get easier, and often with a paroxysm of coughing relief is obtained and he
sinks exhausted to sleep. The relief may be but temporary and a second
attack may soon come on. In a majority of the cases even in the intervals be-
tween the asthmatic fits the respiration is somewhat embarrassed. The cough
is at first very tight and dry and the expectoration is tenacious. Emphysema
of the neck may occur during the violent coughing spells. Urticaria may
break out over the whole body during an attack, or, as in one patient, may
be confined to the skin of the interscapular regions.
The PHYSICAL SIGNS during an attack are very characteristic. On inspec-
tion the thorax looks enlarged, barrel-shaped, and is fixed, the amount of
DISEASES OF THE BRONCHI. 611
expansion being altogether disproportionate to the intensity of the inspiratory
movements. The diaphragm is lowered and moves but slightly. Inspiration is
short and quick, expiration prolonged. Percussion may not reveal any special
difference, but there is sometimes marked hyperresonance, particularly in
cases which have had repeated attacks.
On auscultation, with inspiration and expiration, there are innumerable
sibilant and sonorous rales of all varieties, piping and high-pitched, low-pitched
and grave. Later in the attack there are moist rales.
The sputum in bronchial asthma is quite distinctive, unlike that which
occurs in any other affection. Early in the attack it is brought up with great
difficulty and is in the form of rounded gelatinous masses, the so-called
" perles " of Laennec. Though ball-like, they can be unfolded and really
represent moulds in mucus of the smaller tubes. The entire expectoration may
be made up of these somewhat translucent-looking pellets, floating in a small
quantity of thin mucus. Some of them are opaque. Often with the naked eye
a twisted spiral character can be seen, particularly if the sputum is spread on
a glass with a black background. Microscopically, many of these pellets have
a spiral structure, which renders them among the most remarkable bodies met
with in sputum. It is not a little curious that they should have been practi-
cally overlooked until described by von Curschmann. Under the microscope
the spirals are of two forms. In one there is simply a twisted, spirally arranged
filament of mucin, in which are entangled leucocytes, the majority of which
are eosinophiles. The twist may be loose or tight. The second form is much
more peculiar. In the centre of a tightly coiled skein of mucin fibrils with a
few scattered cells is a filament of extraordinary clearness and translucency,
probably composed of transformed mucin. These spirals are doubtless formed
in the finer bronchioles and constitute the product of an acute bronchiolitis.
It is difficult to explain their spiral nature. I do not know of any observa-
tions upon the course of the currents produced by the ciliated epithelium in
the bronchi, but it is quite possible that their action may be rotatory, in which
case, particularly when combined with spasm of the bronchial muscles, it is
possible to conceive that the mucus formed in the tube might be compelled
to assume a spiral form. Within two or three days the sputum changes entirely
in character; it becomes muco-purulent and von Curschmann's spirals are no
longer to be found. They occur in all instances of true bronchial asthma in
the early period of the attack. I have never seen the true spirals either in
bronchitis or pneumonia. There are, in addition, in many cases, the pointed,
octahedral crystals described by Leyden and sometimes called asthma crystals.
They are identical with the crystals found in the semen and in the blood in
leukaemia. At one time they were supposed, by their irritating character, to
induce the paroxysms. Eosinophiles in the blood are enormously increased
in asthma — to 25 or 35 per cent of the leucocytes, or even to 53.6 per cent in
one case (J. S. Billings, Jr.).
Course. — The course of the disease is very variable. In severe attacks the
paroxysms recur for three or four nights or even more, and in the intervals
and during the day there may be wheezing and cough. Early in the disease
the patient may be free in the morning, without cough or much distress, and
the attacks may appear at first to be of a purely nervous character. In the
long-standing cases emphysema almost invariably develops, and while the pure
612 DISEASES OF THE RESPIRATORY SYSTEM.
asthmatic fits diminish in frequency the chronic bronchitis and shortness of
breath become aggravated.
We have no knowledge of the morlnd anatomy of true asthma. Death dur-
ing the attack is unknown. In long-standing cases the lesions are those of
chronic bronchitis and emphysema.
Treatment. — The asthmatic attack usually demands immediate and prompt
treatment, and remedies should be administered wliich experience has shown
are capable of relieving the condition of the bronchial mucosa. A few whiffs
of chloroform will produce prompt though temporary relaxation. In a child
with ver}' severe attacks, resisting all the usual remedies, the treatment by
chloroform gave immediate and finally permanent relief. H^-podermic injec-
tions of pilocarpin (gr. J) will sometimes relax the mucosa in the profuse
sweating. Perles of nitrite of amyl may be broken on the handkerchief or
from two to five drops of the solution may be placed upon cotton-wool and
inhaled. Strong stimulants given hot or a dose of spirits of chloroform in hot
whisk}^ will sometimes induce relaxation. More permanent relief is given by
the hypodermic injection of morphia or of morphia and cocaine combined.
In obstinate and repeatedly recurring attacks this has proved a ver}^ satisfac-
tory plan. The sedative antispasmodics, such as belladonna, henbane, stra-
monium, and lobelia, may be given in solution or used in the form of ciga-
rettes. Xearly all the popular remedies either in this form or in pastilles
contain some plant of the order solanacece, with nitrate or chlorate of potash.
Excellent cigarettes are now manufactured and asthmatics tr}^ various sorts,
since one form benefits one patient, another form another patient. Xitre
paper made with a strong solution of nitrate of potash is very serviceable.
Filling the room with the fumes of this paper prior to retiring will sometimes
ward off a nocturnal attack. I have known several patients to whom tobacco
smoke inhaled was quite as potent as the prepared cigarettes.
Cauterization of the mucous membrane of the nose has given great relief,
particularly in cases with swelling and irritation. The use of compressed
air in the pneumatic cabinet is very beneficial; oxygen inhalations may also
be tried. In preventing the recurrence of the attacks there is no remedy so
useful as iodide of potassium, which sometimes acts like a specific. From
10 to 20 grains three times a day is usually sufficient.
Particular attention should be paid to the diet of asthmatic patients. A
rule which experience generally compels them to make is to take the heavy
meals in the early part of the day and not retire to bed before gastric diges-
tion is completed. As the attacks are often induced by flatulency, the carbo-
hydrates should be restricted. Coffee is a more suitable drink than tea. In
respect to climate it is very difficult to lay down rules for astlimatics. The
patients are often much better in the city than in the country. The high and
dry altitudes are certainly more beneficial than the sea-shore ; but in protracted
cases, with emphysema as a secondary complication, the rarefied .air of high
altitudes is not advantageous. In young persons I have known a residence for
six months in Florida or southern California to be followed by prolonged
freedom from attacks. Eg}"pt is a peculiarly satisfactor}^ winter climate.
DISEASES OF THE BRONCHI. 613
V. FIBRINOUS BRONCHITIS.
(Plastic or Croupous Bronchitis.)
Definition. — An acute or chronic affection, characterized by the formation
in certain of the bronchial tubes of fibrinous casts, which are expelled in
paroxysms of dyspnoea and cough.
In several diseases fibrinous moulds of the bronchi are formed, as in diph-
theria (with extension into the trachea and bronchi), in pneumonia, and occa-
sionally in phthisis — conditions which, however, have nothing to do with true
fibrinous bronchitis. These casts are not to be confounded with the blood-casts
which occur occasionally in haemoptysis.
Clinical Description. — Bettman, in reporting a case which occurred in Prof.
Whitridge Williams's obstetrical clinic at the Johns Hopkins Hospital, has
analyzed all the cases from the literature since 1869, grouping them into dif-
ferent classes. The first and most important is chronic idiopathic fibrinous
Ironchitis. It is a rare affection. Of 27 cases, 15 were in males. It is most
common at the middle period of life. The attacks may occur at definite inter-
vals for months or years. The form and size of the casts may be identical at
each attack as though each time precisely the same bronchial area was in-
volved. The expectoration of the casts is associated with paroxysms of dysp-
noea and coughing, which occur at longer or shorter intervals. Fever and
hsemoptysis may be present during the attack. Physical signs usually indicate
the portion of the lung affected, as there are suppressed breath sounds and
numerous rales on coughing. A very dry rale, called the " bruit de drapeau,"
has been described, caused by the vibration of a loosened portion of the cast.
In five cases there were skin lesions. Tuberculosis is sometimes present.
Death occurred in only one case of the series. The casts are usually rolled
up and mixed with mucus and blood. When unrolled they are large white
branching structures. The main stem may be as thick as the little finger.
Prom the consistency and appearance they have been described as fibrinous,
but they consist mainly of mucin. On cross-section they show a concentrically
stratified structure, with leucocytes and alveolar epithelium. Leyden's crystals
and von Curschinann's spirals are sometimes found, and in Bettman's case
there were protozoan-like bodies.
There is a very remarkable acute form, of which Bettman has collected
15 cases. It comes on most frequently during some fever, as typhoid, pneu-
monia, or the eruptive fevers. After a preliminary bronchitis the dyspnoea
increases, and then the casts are coughed up. Chills and fever have been
present. Four of the 15 cases proved fatal, and the casts were found in situ.
It is much more serious than the chronic form. There may be casts expec-
torated which have not the arborescent structure of the true fibrinous moulds,
but which come from a single tube or its bifurcation. Sometimes they are
very small and " tail off " into true spirals.
Fibrinous casts are expectorated in connection with chronic heart-disease
(10 cases) and in pulmonary tuberculosis (14 cases), in the latter disease usu-
ally late in the course and of unfavorable moment. In the albuminous expec-
toration following tapping of a pleural exudate fibrinous casts have been
coughed up.
614 DISEASES OF THE RESPIRATORY SYSTEM.
In hgemoptysis blood-casts may be expectorated, and they are not to be
confounded with the casts of true fibrinous bronchitis which may be coughed
up with profuse haemorrhage.
In pneumonia small fibrinous plugs are not uncommon in the sputa, and
in a few rare instances quite large moulds of the tubes may be coughed up.
The mycelium of Aspergillus fumigatus may form membranous casts in
the bronchi. I reported an instance of the kind in which a small partial
mould of this kind was expectorated, and there is on record a case in which
for long periods membranes composed of this fungus were coughed up in
attacks of dyspnoea.
The pathology of the disease is obscure. The membrane is identical with
that to which the term croupous is applied, and the obscurity relates not so
much to the mechanism of the production, which is probably the same as in
other mucous surfaces, as to the curious li;nitation of the affection to certain
bronchial territories and in the chronic form the remarkable recurrence at
stated or irregular intervals throughout a period of man}^ years.
In the fatal cases the bronchial mucous membrane may be found injected
or pale. In Biermer's case the epithelial lining was intact beneath the cast,
but in that of Kretschy the bronchi were denuded of their epitheliimi. Em-
physema is almost invariably present. Evidences of recent or antecedent pleu-
risy are sometimes found. Model, in an article published from Baumler's
clinic, states that tuberculosis was present in 10 out of 21 autopsies.
Treatment. — In the acute cases the treatment should be that of ordinary
acute bronchitis. We know of nothing which can prevent the recurrence of the
attacks in the chronic form. In the uncomplicated cases there is rarely any dan-
ger during the paroxysm, even though the sjanptoms may be most distressing
and the dyspnoea and cough very severe. Inhalations of ether, steam, or
atomized lime-water aid in the separation of the membranes. Waldenberg
employed the last remedy with success in one case. Ewart recommends intra-
tracheal injections of olive oil. Pilocarpine might be useful, as in some in-
stances it increases the bronchial secretion. The emplo3rment of emetics may
be necessary, and in some cases they are effective in promoting the removal of
the casts.
D. DISEASES OE THE LUNGS.
I. CIRCULATORY DISTURBANCES IN THE LUNGS.
Congestion. — There are two forms of congestion of the lungs — active and
passive.
(1) Active Coxgestion of the Luisras. — Much doubt and confusion still
exist on this subject. French writers, following Woillez, regard it as an inde-
pendent primary affection (maladie de Woillez), and in their dictionaries and
text-books allot much space to it. English and American authors more cor-
rectly regard it as a symptomatic affection. Active fluxion to the lungs occurs
with increased action of the heart, and when very hot air or irritating sub-
stances are inhaled. In diseases which interfere locally with the circulation
the capillaries in the adjacent unaffected portions may be greatly distended.
The importance, however, of this collateral fluxion, as it is called, is probably
DISEASES OP THE LUNGS. 615
exaggerated. In a whole series of pulmonary affections there is this asso-
ciated congestion — in pneumonia, bronchitis, pleurisy, and tuberculosis.
The symptoms of active congestion of the lungs are by no means definite.
The description given by Woillez and by other French writers is of an affec-
tion which is difficult to recognize from anomalous or larval forms of pneu-
monia. The chief symptoms described are initial chill, pain in the side, dysp-
noea, moderate cough, and temperature from 101° to 103°. The physical signs
are defective resonance, feeble breathing, sometimes bronchial in character, and
fine rales. A majority of clinical physicians would undoubtedly class such
cases under inflammation of the lung. In many epidemics the abnormal and
larval forms are specially prevalent.
The occurrence of an intense and rapidly fatal congestion of the lung, fol-
lowing extreme heat or cold or sometimes violent exertion, is recognized by
some authors. Renforth, the oarsman, is said to have died from this cause
during the race at Halifax. Leuf has described cases in which, in association
with drunkenness, exposure, and cold, death occurred suddenly, or within
twenty-four hours, the only lesion found being an extreme, almost hasmor-
rhagic, congestion of the lungs. It is by no means certain that in these cases
death really occurs from pulmonary congestion in the absence of specific state-
ments with reference to the coronary arteries and the heart.
(2) Passive Congestion. — Two forms of this may be recognized, the me-
chanical and the hypostatic.
(a) Mechanical congestion occurs whenever there is an obstacle to the
return of the blood to the heart. It is a common event in many affections
of the left heart. The lungs are voluminous, russet brown in color, cutting
and tearing with great resistance. On section they show at first a brownish-
red tinge, and then the cut surface, exposed to the air, becomes rapidly of a
vivid red color from oxidation of the abundant hgemoglobin. This is the con-
dition known as hrown induration of the lung. Histologically it is charac-
terized by (a) great distention of the alveolar capillaries; (/3) increase in
the connective-tissue elements of the lung; (y) the presence in the alveolar
walls of many cells containing altered blood-pigment ; (8) in the alveoli numer-
ous epithelial cells containing blood-pigment in all stages of alteration, which
are also found in great numbers in the sputum.
It occasionally happens that this mechanical hypersemia of the lung results
from pressure by tumors. So long as compensation is maintained the mechan-
ical congestion of the lung in heart-disease does not produce any symptoms,
but with enfeebled heart action the engorgement becomes marked and there
are dyspnoea, cough, and expectoration, with the characteristic alveolar cells.
{!)) Hypostatic congestion. In fevers and adynamic states generally, it is
very common to find the bases of the lungs deeply congested, a condition in-
duced partly by the effect of gravity, the patient lying recumbent in one pos-
ture for a long time, but chiefly by weakened heart action. That it is not an
effect of gravity alone is shown by the fact that a healthy person may remain
in bed an indefinite time without its occurrence. The posterior parts of the
lung are dark in color and engorged with blood and serum ; in some instances
to such a degree that the alveoli no longer contain air and portions of the lung
sink in water. The terms splenization and hypostatic pneumonia have been
given to these advanced grades. It is a common affection in protracted cases
616 DISEASES OF THE RESPIRATORY SYSTEM.
of typhoid fever and in long debilitating illnesses. In ascites, meteorism, and
abdominal tumors the bases of the lungs ma}^ be compressed and congested. In
this connection must be mentioned the form of passive congestion met with
in injury to, and organic disease of, the brain. In cerebral apoplexy the bases
of the lungs are deepty engorged, not quite airless, but heavy, and on section
drip with blood and serum. I have twice seen this condition in an extreme
grade throughout the lungs in death from morphia poisoning. In some in-
stances the lung tissue has a blackish, gelatinous, infiltrated appearance, almost
like diffuse pulmonary apoplex}'. Occasionally this congestion is most marked
in, and even confined to, the hemiplegic side. In prolonged coma the hypo-
static congestion may be associated with patches of consolidation, due to the
aspiration of portions of food into the air-passages.
The s}Tnptoms of hypostatic congestion are not at all characteristic, and
the condition has to be sought for by careful examination of the bases of the
lungs, when slight dulness, feeble, sometimes blowing, breathing and liquid
rales can be detected.
Teeatmext. — The treatment of congestion of the limgs is usually that
of the condition with which it is associated. In the intense pulmonary en-
gorgement, which may possibly occur primarily, and which is met with in
heart-disease and emphysema, free bleeding should be practised. From 20 to
30 ounces of blood should be taken from the arm, and if the blood does not
flow freely and the condition of the patient is desperate, aspiration of the
right auricle may be performed.
(Edema. — In all forms of intense congestion of the lungs there is a transu-
dation of serum from the engorged capillaries chiefly into the air-cells, but
also into the alveolar walls. Xot only is it very frequent in congestion, but
also with inflammation, with new growths, infarcts, and tubercles. When
limited to the neighborhood of an affected part, the name collateral oedema
is sometimes applied to it.
Acute cedema is met with: (1) in the infections; (2) in Bright's disease;
(3) in heart disease, particularly angina pectoris, myocarditis, and valve
lesions; (4) in arterio-sclerosis ; (5) pregnancy; (6) angio-neurotic redema,
and (7) as a complication of the epileptic flt. The theory most generally
accepted is that of "Welch, whose experiments seemed to indicate that pul-
monar}' cedema is due to a disproportionate wealaiess of the left ventricle, so
that the blood accumulates in the lung capillaries until transudation occurs.
Such weakness may be brought about by paralysis or by spasm of the left
ventricle. Others regard is as an effect of disturbance in the vasomotor
mechanism of the lungs.
Anatomically the lung is ansemic, heavy, sodden, pits on pressure, and on
section a large quantity of clear or blood-tinged serum flows out. It may
have in places a gelatinous aspect.
Symptoms. — The onset is sudden with a feeling of oppression and pain
in the chest and rapid breathing which soon becomes dyspnreic or orthopnoeic.
There may be an incessant short cough and a copious frothy, sometimes blood-
tinged, expectoration, which may be expelled in a gush from the mouth and
nose. The face is pale and covered with a cold sweat; the pulse is feeble and
the heart's action weak. Over the entire chest may be heard piping and
bubbling rales. The attack may be fatal in a few hours or it may persist
DISEASES OF THE LUNGS. 617
for twelve or twenty-four hours and then pass off. Steven, of Glasgow, has
reported a case with 73 attacks in two and a half years. I have seen this
recurrent form in angina pectoris, each paroxysm of which was associated
with intense dyspnoea and all the features of acute oedema of the lungs.
Bleeding should be practised at once and is often most helpful. Dry
cupping may be tried. One of my patients had great relief from inhalations
of chloroform. Oxygen may be used. If there is much agitation and sense
of impending death, morphia may be given hypodermically.
Pulmonary Hsemorrhage. — This occurs in two forms — broncho-pulmonary
hwmorrhage, sometimes called bronchorrhagia, in which the blood is poured
out into the bronchi and is expectorated, and pulmonary apoplexy or pneumor-
rhagia, in which the hsemorrhage takes place into the air-cells and the lung
tissue.
1. Broncho-pulmonaet Hemorrhage; Hemoptysis. — Spitting of
blood, to which the term haemoptysis should be restricted, results from a vari-
ety of conditions, among which the following are the most important: (a) In
young healthy persons haemoptysis may occur without warning, and after con-
tinuing for a few days disappear and leave no ill traces. There may be at
the time of the attack no physical signs" indicating pulmonary disease. In
such cases good health may be preserved for years and no further trouble
occur. These cases are not very uncommon, and in spite of the good health
tuberculosis may be suspected. In Ware's important contribution to this sub-
ject,* of 386 cases of haemoptysis noted in private practice 63 recovered and
pulmonary disease did not subsequently develop in them. (&) Hcemoptysis
in pulmonary tuberculosis, which is considered on page 325. (c) In con-
nection with certain diseases of the lung, as pneumonia (in the initial stage)
and cancer, occasionally in gangrene, abscess, and bronchiectasis, (d) In
many heart affections, particularly mitral lesions. It may be profuse and
recur at intervals for years, (e) In ulcerative affections of the larynx,
trachea, or bronchi. Sometimes the haemorrhage is profuse and rapidly fatal,
as when the ulcer erodes a large branch of the pulmonary artery, an accident
which I have known to happen in a case of chronic bronchitis with emphy-
sema. (/) Aneurism is an occasional cause of hemoptysis. It may be sudden
and rapidly fatal when the sac bursts into the air-passages. Slight bleeding
may continue for weeks or months, due to pressure on the mucous membrane
or erosion of the lung ; or in some cases the sac " weeps " through the exposed
laminae of fibrin, (g) Vicarious hcemorrhage, which occurs in rare instances
in cases of interrupted menstruation. The instances are well authenticated.
Flint mentions a case which he had had under observation for four years,
and Hippocrates refers to it in the aphorism, " Haemoptysis in a woman is
removed by an eruption of the menses." Periodical hsemoptysis has also been
met with after the removal of both ovaries. Even fatal haemorrhage has
occurred from the lung during menstruation when no lesion was found to
account for it. (h) There is a form of recurring hcemoptysis in arthritic
subjects to which Sir Andrew Clark has called special attention and which
also is described by French writers. The cases occur in persons over fifty
years of age who usually present signs of the arthritic diathesis. It rarely
* On Haemoptysis as a Symptom, by John Ware, M.D.
618 DISEASES OF THE RESPIRATORY SYSTEM.
leads to fatal issue and subsides without inducing pulmonary changes, (i)
Hemoptysis occurs sometimes in malignant fevers and in purpura licenwr-
rliagica. Lastly, there is endemic hsemoptysis, due to the bronchial fluke, an
affection which is confined to parts of China and Japan,
Symptoms. — Hgemoptysis sets in as a rule suddenly. Often without warn-
ing the patient experiences a warm, saltish taste as the mouth fills with blood.
Coughing is usually induced. There may be only an ounce or so brought up
before the haemorrhage stops, or the bleeding may continue for days, the
patient bringing up small quantities. In other instances, particularly when
a large vessel is eroded or an aneurism bursts, the amount is large, and the
patient after a few attempts at coughing shows signs of suffocation and death
is produced by inundation of the bronchial system. Fatal hsemorrhage even
ma}^ occur into a large cavity in a patient debilitated by phthisis without the
production of hsemoptysis. I dissected a case of this kind at the Philadelphia
Hospital. The blood from the lungs generally has characters which render
it readily distinguishable from the blood which is vomited. It is alkaline
in reaction, frothy, and mixed with mucus, and when coagulation occurs air-
bubbles are present in the clot. Blood-moulds of the smaller bronchi are
sometimes seen. Patients can usually tell whether the blood has been brought
up by coughing or by vomiting, and in a majority of cases the history gives
important indications. In paroxysmal hsemoptysis connected with menstrual
disturbances the practitioner should see that the blood is actually coughed
up, since deception may be practised. The spurious haemoptysis of hysteria is
considered with that disease. Naturally, the patient is at first alarmed at the
occurrence of bleeding, but, unless very profuse, as when due to rupture of
an aortic aneurism in a pulmonary cavity, the danger is rarely immedi-
ate. The attacks, however, are apt to recur for a few days and the sputa
may remain blood-tinged for a longer period. In the great majority of
cases the hemorrhage ceases spontaneously. It should be remembered that
some of the blood may be swallowed and produce vomiting, and, after a day
or two, the stools may be dark in color. It is not well during an attack of
hsemoptysis to examine the chest.
2. Pulmonary Apoplexy; Hemorrhagic Infarct. — In this condition
the blood is effused into the air-cells and interstitial tissue. It is usually
diffuse, the parenchyma not being broken, as is the brain tissue in cerebral
apoplexy. Sometimes, in disease of the brain, in septic conditions, and in
the malignant forms of fevers, the lung tissue is uniformly infiltrated with
blood and has, on section, a black, gelatinous appearance.
As a rule, the haemorrhage is limited and results from the blocking of
a branch of the pulmonary artery either \)j a thrombus or an embolus. The
condition is most common in chronic heart-disease. Although the pulmonary
arteries are terminal ones, blocking is not always followed by infarction;
partly because the wide capillaries furnish sufficient anastomosis, and partly
because the bronchial vessels may keep up the circulation. The infarctions
are chiefly at the periphery of the lung, usually wedge-shaped, with the base
of the wedge toward the surface. When recent, they are dark in color, hard
and firm, and look on section like an ordinary blood-clot. Gradual changes
go on, and the color becomes a reddish-brown. The pleura over an infarct
is usually inflamed. A microscopical section shows the air-cells to be dis-
DISEASES OF THE LUNGS. 619
tended with red blood-corpuscles, which may also be in the alveolar walls.
The infarcts are usually multiple and vary in size from a walnut to an orange.
Very large ones may involve the greater part of a lobe. In the artery passing
to the affected territory a thrombus or an embolus is found. The globular
thrombi, formed in the right auricular appendix, play an important part
in the production of hsemorrhagic infarction. In many cases the source of
the embolus cannot be discovered, and the infarct may have resulted from
thrombosis in the pulmonary artery, but, as before mentioned, it is not infre-
quent to find total obstruction of a large branch of a pulmonary artery without
haemorrhage into the corresponding lung area. The further history of an in-
farction is variable. It is possible that in some instances the circulation is
re-established and the blood removed. More commonly, if the patient lives,
the usual changes go on in the extravasated blood and ultimately a pigmented,
puckered, fibroid patch results. Sloughing may occur with the formation of a
cavity. Occasionally gangrene results. In a case at the University Hospital,
Philadelphia, a gangrenous infarct ruptured and produced fatal pneumo-
thorax.
The symptoms of pulmonary apoplexy are by no means definite. The
condition may be suspected in chronic heart-disease when haemoptysis occurs,
particularly in mitral stenosis, but the bleeding may be due to the extreme
engorgement. When the infarcts are very large, and particularly in the lower
lobe, in which they most commonly occur, there may be signs of consolidation
with blowing breathing and a pleuritic friction.
Treatment of Pulmoistary Hemorrhage. — The pressure within the
pulmonary artery is considerably less than that in the aortic system. The
system is under vaso-motor control, but our knowledge of the mutual rela-
tions of pressure in the aorta and in the pulmonary artery, under varying
conditions, is still very imperfect (Bradford). There may be an influence
on the systemic blood-pressure without any on the pulmonary, and the pres-
sure in the one may rise while it falls in the other, or it may rise and fall in
both together. The researches of Brodie and Dixon indicate that drugs which
raise the peripheral blood-pressure by vaso-constriction increase the total blood
in the lung. Thus ergot, the remedy perhaps most commonly used, causes a
distinct rise in the pulmonary blood-pressure, while aconite produces a definite
fall.
The anatomical condition in haemoptysis is either hyperaemia of the bron-
chial mucosa (or of the lung tissue) or a perforated vessel. In the latter case
the patient often passes rapidly beyond treatment, though there are instances
of the most profuse haemorrhage, which must have come from a perforated
artery or a ruptured aneurism, in which recovery has occurred. Practically,
for treatment, we should separate these cases, as the remedies which would be
applicable in the case of congested and bleeding mucosa would be as much
out of place in a case of haemorrhage from ruptured aneurism as in a cut
radial artery. When the blood is brought up in large quantities, it is almost
certain either that an aneurism has ruptured or a vessel has been eroded. In
the instances in which the sputa are blood-tinged or' when the blood is in
smaller quantities, bleeding comes by diapedesis from hyperaemie vessels. In
such cases the haemorrhage may be beneficial in relieving the congested blood-
vessels.
620 DISEASES OF THE RESPIRATORY SYSTEM.
The indications are to reduce the frequency of the heart-l^eats and to
lower the hlood-pressure. The truth, Das Blut ist ein ganz besonderer Saft,
is strikingly emphasized by the frightened state of the patient. Eest of the
body and peace of the mind — " quies, securitas, silentium " of Celsus — should
be secured. Turn the patient on the affected side, if known, as the regur-
gitation is less apt to occur into the bronchi of the sound lung. As Aretseus
remarks, in hgemoptysis the patient despairs from the first, and needs to be
strongly reassured. Death is rarely due directly to hsemoptysis; patients die
after, not of it (S. West). In the majority of cases of mild haemoptysis this
is sufficient. Even when the patient insists upon going about, the bleeding
may stop spontaneously. The diet should be light and unstimulating. xllcohol
should not be used. The patient may, if he wishes, have ice to suck. Small
doses of aromatic sulphuric acid may be given, but unless the bleeding is
protracted st)^tic and astringent medicines are not indicated. For cough,
which is always present and disturbing, opiuni should be freely given, and
is of all mediciries most serviceable in hsemoptysis. Digitalis should not be
used, as it raises the blood-pressure in the pulmonary artery. Aconite, as it
lowers the pressure, may be used when there is much vascular excitement.
Ergot, tannic acid, and lead, which are so much employed, have little or no
influence in hsemoptysis; ergot probabl}^ does harm. One of the most satis-
factory means of lowering the blood-pressure is purgation, and when the bleed-
ing is protracted salts may be freely given. In profuse haemoptysis, such as
comes from erosion of an artery or the rupture of an aneurism, a fatal result
is common, and yet post-mortem evidence shows that thrombosis may occur
with healing in a rupture of considerable size. The fainting induced by the
loss of blood is probably the most efficient means of promoting thrombosis,
and it was on this principle that formerly patients were bled from the arm,
or from both arms, as in the case of Laurence Sterne. Ligatures, or Esmarch's
bandages, placed around the legs may serve temporarily to cheek the bleeding.
The ice-bag on the sternum is of doubtful utility. In a protracted case Cayley
induced pneumothorax, but without effect.
Briefly, then, we may say that hemorrhage from rupture of aneurism or
erosion of a blood-vessel usually proves fatal. The fainting induced by the loss
of blood is beneficial, and, if the patient can be kept alive for twenty-four
hours, a thrombus of sufficient strength to prevent further bleeding may form.
The chief danger is the inundation of the bronchial system with the blood, so
that while the hasmorrhage is profuse the cough should be encouraged. Opium
should not then be used, and stimulants should be given with caution.
In the other group, in which the haemorrhage comes from a congested
area and is limited, the patient gets well if kept absolutely quiet, and fatal
hgemorrhage probably never occurs from this source. Eest, reduction of
the blood-pressure by minimum diet, purging, if necessary, and the admin-
istration of opium to allay the cough are the main indications.
n. BRONCHO-PNETJMONLA. (CapiUary Bronchitis).
This is essentially an inflammation of the terminal bronchus and the air-
vesicles which make up a pulmonary lobule, whence the term broncho-pneu-
monia. It is also known as lobular, in contradistinction to lobar pneumonia.
DISEASES OF THE LUNGS. 621
The term catarrhal is less applicable. The process begins usually with an
inflammation of the capillary bronchi, which is a condition rarely, if ever,
found without involvement of the lobular structures, so that it is now custom-
ary to consider the affections together. All forms of broncho-pneumonia
depend upon invasion of the lung with microbes, and it would have been more
consistent to place them with lobar pneumonia among the infectious dis-
orders, but it is well perhaps to defer this until the bacteriology of the different
varieties has been more fully worked out.
Etiology. — Broncho-pneumonia occurs either as a primary or as a sec-
ondary affection. The relative frequency in 443 cases is thus given by Holt:
Primary, without previous bronchitis, 154; secondary (a) to bronchitis of
larger tubes, 41; to measles, 89; to whooping-cough, 66; to diphtheria, 47;
to scarlet fever, 7 ; to influenza, 6 ; to varicella, 2 ; to erysipelas, 2 ; and to
acute ileo-colitis, 19. The proportion of primary to secondary forms as shown
in this list is probably too low.
Pkimary acute broncho-pneumonia, like the lobar form, attacks chil-
dren in good health, usually under two years. The etiological factors are very
much those of ordinary pneumonia, and probably the pneumococcus is more
often associated with it.
Secondary broncho-pneumonia occurs in two great groups: 1. As a
sequence of the infectious fevers — measles, diphtheria, whooping-cough, scar-
let fever, and, less frequently, small-pox, erysipelas, and typhoid fever. In
children it forms the most serious complication of these diseases, and in
reality causes more deaths than are due directly to the fevers. In large cities
it ranks next in fatality to infantile diarrhoea. Following, as it does, the
contagious diseases which principally affect children, we find that a large
majority of cases occur during early life. According to Morrill's Boston sta-
tistics, it is most fatal during the first two years of life. The number of cases
in a community increases or decreases with the prevalence of measles, scarlet
fever, and diphtheria. It is most prevalent in the winter and spring months.
In the febrile affections of adults broncho-pneumonia is not very common.
Thus in typhoid fever it is not so frequent as lobar pneumonia, though isolated
areas of consolidation at the bases are by no means rare in protracted' cases
of this disease. In old people it may follow debilitating causes of any sort,
and is met with in the course of chronic Bright's disease and various acute
and chronic maladies.
2. In the second division of this affection are embraced the cases of
so-called aspiration or deglutition pneumonia. Whenever the sensitiveness of
the larynx is benumbed, as in the coma of apoplexy or ursemia, minute par-
ticles of food or drink are allowed to pass the iima, and, reaching finally the
smaller tubes, excite an intense inflammation similar to the vagus pneumonia
which follows the section of the pneumogastrics in the dog. Cases are very
common after operations about the mouth and nose, after tracheotomy, and
in cancer of the larynx and oesophagus. The aspirated particles in some
instances induce such an intense broncho-pneumonia that suppuration or even
gangrene supervenes. The ether pneumonia, already described, is often lobu-
lar in type.
An aspiration broncho-pneumonia may follow hemoptysis (which has been
already considered), the aspiration of material from a bronchiectatic cavity,
622 DISEASES OF THE RESPIRATORY SYSTEM.
and occasionally the material from an empyema which has ruptured into the
lung.
A common and fatal form of broncho-pneumonia is that excited by the
tubercle bacillus, which has already been considered.
Among general predisposing causes may be mentioned age. As just noted,
it is prone to attack infants, and a majority of cases of pneumonia in chil-
dren under five years of age are of this form. Of 370 cases in children under
five years of age, 75 per cent were broncho-pneumonia (Holt). At the oppo-
site extreme of life it is also common, in association with various debilitating
circumstances and with the chronic diseases incident to the old. In children,
rickets and diarrhoea are marked predisposing causes, and broncho-pneumonia
is one of the most frequent post-mortem-room lesions in infants' homes and
foundling asylums. The disease prevails most extensively among the poorer
classes.
Morbid Anatomy. — On the pleural surfaces, particularly toward the base,
are seen depressed bluish or blue-brown areas of collapse, between which the
lung tissue is of a lighter color. Here and there are projecting portions over
which the ^^leura ma}' be slightly turbid or granular. The lung is fuller and
firmer than normal, and, though in great part crepitant, there can be felt
in places throughout the substance solid, nodular bodies. The dark depressed
areas may be isolated or a large section of one lobe may be in the condition
of collapse or atelectasis. Gradual infiation by a blow-pipe inserted in the
bronchus will distend a great majority of these collapsed areas. On section,
the general surface has a dark reddish color and usually drips blood. Project-
ing above the level of the section are lighter red or reddish-gray areas repre-
senting the patches of broncho-pneumonia. These may be isolated and sepa-
rated from each other by tracts of uninflamed tissue or they may be in groups ;
or the greater part of a lobe may be involved. Study of a favorable section
of an isolated patch shows : (a) A dilated central bronchiole full of tenacious
purulent mucus. A fortunate section parallel to the long axis may show a
racemose arrangement — the alveolar passages full of muco-pus. (&) Sur-
rounding the bronchus for from 3 to 5 mm. or even more, an area of grapsh-
red consolidation, usually elevated above the surface and firm to the touch.
Unlike the consolidation of lobar pneumonia, it may present a perfectly smooth
surface, though in some instances it is distinctly granular. In a late stage of
the disease small grayish-white points may be seen, which on pressure may be
squeezed out as purulent droplets. A section in the axis of the lobule may
present a somewhat grape-like arrangement, the stalks and stems represent-
ing the bronchioles and alveolar passages filled with a yellowish or grayish-
white pus, while surrounding them is a reddish-brown hepatized tissue, (c)
In the immediate neighborhood of this peribronchial inflammation the tissue
is dark in color, smooth, airless, at a somewhat lower level than the hepatized
portion, and differs distinctly in color and appearance from the other por-
tions of the lung. This is the condition to which the term splenization has
been given. It really represents a tissue in the early stage of inflamma-
tion, and it perhaps would be as well to give up the use of this term and
also that of carnification, which is only a more advanced stage. The con-
dition of collapse probably always precedes this, and it is difficult in
some instances to tell the difference, as one shades into the other. In fact.
DISEASES OF THE LUNGS. 623
collapse, splenization, and carnification are but preliminary steps in broncho-
pneumonia.
While, in many cases, the areas of broncho-pneumonia present a reddish-
brown color and are indistinctly granular, in others, particularly in adults, the
nodules may resemble more closely gray hepatization and the air-cells are filled
with a grayish muco-purulent material. Minute hgemorrhages are sometimes
seen in the neighborhood of the inflamed areas or on the pleural surfaces.
Emphysema is commonly seen at the anterior borders and upper portions of
the lung or in lobules adjacent to the inflamed ones. In many cases following
diphtheria and measles the process is so extensive that the greater part of a
lobe is involved, and it looks like a case of lobar hepatization. It has not,
however, the uniformity of this affection, and collapsed dark strands may be
seen between extensive areas of hepatized tissue.
There are three groups of cases: (1) Those in which the bronchitis and
bronchiolitis are most marked, and in which there may be no definite con-
solidation, and yet on microscopical examination many of the alveolar pas-
sages and adjacent air-cells appear filled with inflammatory products. (3)
The disseminated broncho-pneumonia, in which there are scattered areas of
peribronchial hepatization with patches of collapse, while a considerable pro-
portion of the lobe is still crepitant. This is by far the most common condi-
tion. (3) The pseudo-lobar form, in which the greater portion of the lobe
is consolidated, but not uniformly, for intervening strands of dark congested
lung tissue separate the groups of hepatized lobules.
Microscopically, the centre of the bronchus is seen filled with a plug of
exudation, consisting of leucocytes and swollen epithelium. Section in the
long axis may show irregular dilatations of the tube. The bronchial wall is
swollen and infiltrated with cells. Under a low power it is readily seen that
the air-cells next the bronchus are most densely filled, while toward the per-
iphery the alveolar exudation becomes less. The contents of the air-cells are
made up of leucocytes and swollen epithelial cells in varying proportions.
Eed corpuscles are not often present and a fibrin network is rarely seen,
though it may be present in some alveoli. In the swollen walls are seen dis-
tended capillaries and numerous leucocytes. As Delafield has pointed out,
the interstitial inflammation of the bronchi and alveolar walls is the special
feature of broncho-pneumonia.
The histological changes in the aspiration or deglutition broncho-pneu-
monia differ from the ordinary post-febrile form in a more intense infiltra-
tion of the air-cells with leucocytes, producing suppuration and foci of soften-
ing ; even gangrene may be present.
Bacteriology of Broncho-pneumonia. — The organisms most commonly
found in broncho-pneumonia are Micrococcus lanceolatus. Streptococcus py-
ogenes (either alone or with the pneumococcus). Staphylococcus aureus et
alhus, and Friedlander's Bacillus pneumonice. The Klebs-Loefiler bacillus is
not infrequently found in the secondary lesions of diphtheria. Except the
pneumococcus these microbes are rarely found in pure cultures. In the lobu-
lar type the streptococcus is the most constant organism, in the pseudo-lobar
the pneumococcus. Mixed infections are almost the rule in broncho-pneu-
monia.
M. WoUstein, in 17 primary cases, found Micrococcus lanceolatus alone
624 DISEASES OF THE RESPIRATORY SYSTEM.
in 9, with the streptococcus in 7. Of 14 secondary cases Micrococcus lanceo-
latus was found alone in 2 and with other organisms in 9. The primary
form is the result of infection with the pneumococcus, the secondary most
often with the streptococcus.
Terminations of Broncho-pneumonia. — (1) In resolution, which when it
once begins goes on more rapidly than in fibrinous pneumonia. Broncho-
pneumonia of the apices, in a child, persisting for three or more weeks,
particularly if it follows measles or diphtheria, is often tuberculous. In these
instances, when resolution is supposed to be delayed, caseation has in reality
taken place. (2) In suppuration, wliich is rarely seen apart from the aspira-
tion and deglutition forms, in which it is extremely common. (3) In gan-
grene, which occurs under the same conditions. (4) In fibroid changes —
chronic hroncho-pneumonia — a rare termination in the simple, a common
sequence of the tuberculous, disease. Formerly it was thought that one of
the most common changes in broncho-pneumonia, particularly in children,
was caseation ; but this is really a tuberculous process, the natural termination
of an originally specific broncho-pneumonia. It is of course quite possible
that a broncho-pneumonia, simple in its origin, may subsequentl}^ be the seat
of infection by Bacillus tuberculosis.
Symptoms. — The primary form sets in abruptly with a chill or a con-
vulsion. The child has not had a previous illness, but there may have been
slight exposure. The temperature rises rapidly and is more constant; the
physical signs are more local and there is not the wide-spread diffuse catarrh
of the smaller tubes. Many cases are mistaken for lobar pneumonia. In
others the pulmonary features are in the background or are overlooked in
the intensit}^ of the general or cerebral sjonptoms. The termination is often
by crisis, and the recovery is prompt. The mortality of this form is slight.
S. "West has called attention to the importance of recognizing these primary
cases and to their resemblance in clinical features with acute lobar pneumonia.
The secondary form begins usually as a bronchitis of the smaller tubes. Much
confusion has arisen from the description of capillary bronchitis as a sepa-
rate affection, whereas it is only a part, though a primary and important one,
of broncho-pneumonia. At the outset it may be said that if in convalescence
from measles or in whooping-cough a child has an accession of fever with
cough, rapid pulse, and rapid breathing, and if, on auscultation, fine rales
are heard at the bases, or widely spread throughout the lungs, even though
neither consolidation nor blowing breathing can be detected, the diagnosis
of broncho-pneumonia may safely be made, I have never seen in a fatal case
after diphtheria or measles a capillary bronchitis as the sole lesion. The onset
is rarel}^ sudden, or with a distinct chill; but after a day or so of indisposi-
tion the child gets feverish and begins to cough and to get short of breath.
The fever is extremely variable; a range of from 102° to 104° is common.
The skin is very dry and pungent. The cough is hard, distressing, and may
be painful. Dyspnoea gradually becomes a prominent feature. Expiration
may be jerky and grunting. The respirations may rise as high as 60 or even
80 per minute. Within the first forty-eight hours the percussion resonance is
not impaired; the note, indeed, may be very full at the anterior borders of
the lungs. On auscultation, many rales are heard, chiefly the fine subcrepitant
variety, with sibilant rhonchi. There may really be no signs indicating that
DISEASES OF THE LUNGS. 625
the pareiich3^ma of the lung is involved, and yet even at this early stage, within
forty-eight hours of the onset of the pulmonary symptoms, I have repeatedly,
after diphtheria, found scattered nodules of lobular hepatization. Northrup,
in a case in which death occurred within the first twenty-four hours, in addi-
tion to the extensive involvement of the smaller bronchi, found the intra-
lobular tissue also involved in places. The dyspnoea is constant and progres-
sive and soon signs of deficient aeration of the blood are noted. The face
becomes a little suffused and the finger-tips bluish. The child has an anxious
expression and gradually enters upon the most distressing stage of asphyxia.
At first the urgency of the symptoms is marked, but soon the benumbing influ-
ence of carbon dioxide on the nerve-centres is seen and the child no longer
makes strenuous efforts to breathe. The cough subsides, and, with a gradual
increase in lividity and a drowsy restlessness, the right ventricle becomes more
and more distended, the bronchial rales become more liquid as the tubes fill
with mucus, and death occurs from heart paralysis. These are symptoms of
a severe case of broncho-pneumonia, or what the older writers called suffocative
catarrh.
The PHYSICAL SIGNS may at first be those of capillary bronchitis, as indi-
cated by the absence of dulness, the presence of fine subcrepitant and whistling
rales. In many cases death takes place before any definite pneumonic signs
are detected. When these exist they are much more frequent at the bases,
where there may be areas of impaired resonance or even of positive dulness.
When numerous foci involve the greater part of a lobe the breathing may
become tubular, but in the scattered patches of ordinary broncho-pneumonia,
following the fevers, the breathing is more commonly harsh than blowing.
In grave cases there is retraction of the base of the sternum and of the lower
costal cartilages during inspiration, pointing to deficient lung expansion.
Diagnosis. — With lobar pneumonia it may readily be confounded if the
areas of consolidation are large and merged together. It is to be remembered,
as Holt's figures well show, that broncho-pneumonia occurs chiefly in children
under one year, whereas lobar pneumonia is more common after the third
year. No writer has so clearly brought out the difference between pneumonia
at these periods as Gerhard,* of Philadelphia, whose papers on this subject
have the freshness and accuracy which characterized all the writings of that
eminent physician. Between lobar pneumonia and the secondary form of
broncho-pneumonia the diagnosis is easy. The mode of onset is essentially
different in the two infections, the one developing insidiously in the course
or at the conclusion of another disease, the other setting in abruptly in a
child in good health. In lobar pneumonia the disease is almost always uni-
lateral, in broncho-pneumonia bilateral. The chief trouble arises in cases of
primary broncho-pneumonia, which by aggregation of the foci involves the
greater part of one lobe. Here the difficulty is very great, and the physical
signs may be practically identical, but in broncho-pneumonia it is much more
likely that a lesion, however slight, will be found on the other side.
A still more difficult question to decide is whether an existing broncho-
pneumonia is simple or tuberculous. In many instances the decision cannot
be made, as the circumstances under which the disease occurs, the mode of
* American Journal of Medical Sciences, vols, xiv and xv.
41
626 DISEASES OF THE RESPIRATORY SYSTEM.
OTiaet. and the physical signs may be identicah It has often been my expe-
rience that a case has been sent do\m from the children's ward to the dead-
house -with the diagnosis of post-febrile broncho-pneumonia in which there
was no suspicion of the existence of tuberculosis; but on section there were
found tuberculous bronchial glands and scattered areas of broncho-pneumonia,
some of which were distinctly caseous, while others showed signs of softening.
I have already spoken fully of this in the section on tuberculosis, but it is
well to emphasize the fact that there are many cases of broncho-pneumonia
in children wliich time alone enables us to distinguish from tuberculosis. The
existence of extensive disease at the apices or central regions is a suggestive
indication, and signs of softening may be detected. In the vomited matter,
wliich is brought up after severe spells of coughing, sputum may be picked
out and elastic tissue and bacilli detected.
It is a superfluous refinement to make a diagnosis between capillary bron-
chitis and catarrhal pneumonia, for the two conditions are part and parcel
of the same disease. In simple bronchitis involving the larger tulles urgent
dyspnoea and pulmonary distress are rarely present and the rales are coarser
and more sibilant. It must not be forgotten that, as in lobar pneumonia,
cerebral s^Tuptoms may mask the true nature of the disease, and may even
lead to the diagnosis of meningitis. I recall more than one instance in
which it could not be satisfactorily determined whether the infant had tuber-
culous meningitis or a cerebral complication of an acute pulmonary affection.
Prognosis. — In the primary form the outlook is good. In children en-
feebled by constitutional disease and prolonged fevers broncho-pneumonia is
terribly fatal, but in cases coming on in connection with whooping-cough or
after measles recovery may take place in the most desperate cases. It is in
this disease that the truth of the old maxim is shown — '" Xever despair of
a sick child.*^ The death-rate in children under five has been variously esti-
mated at from 30 to 50 per cent. After diphtheria and measles thin, wiry
children seem to stand broncho-pneumonia much better than fat, flabby ones.
In adults the aspiration or deglutition pneumonia is a very fatal disease.
Prophylaxis. — Much can be done to reduce the probabilit}' of attack after
feljrile affections. Thus, in the convalescence from measles and whooping-
cough, it is very important that the child should not be exposed to cold,
particularly at night, when the temperature of the room naturally falls. In
" nocturnal visit to the nursery — sometimes, too, I am sorry to say, to a
children's hospital — ^how often one sees children almost naked, having kicked
aside the bedclothes and having the night-clothes up about the arms ! The
use of light flannel " combinations " obviates this nocturnal chill, which is,
I am sure, an important factor in the colds and pulmonary affections of young
children, both in private houses and in institutions. The catarrhal troubles
of the nose and throat should be carefully attended to, and during fevers
the mouth should be washed two or three times a day with an antiseptic
solution.
Treatment. — The frequency and the seriousness of broncho-pneumonia
render it a disease which taxes to the utmost the resources of the prac-
titioner. There is no acute pulmonary affection over which he at times so
greatly despairs. On the other hand, there is not one in which he will be
more gratified in saving cases which have seemed past all succor. The gen-
DISEASES OF THE LUNGS. 627
eral arrangements should receive special attention. The room should be kept
at an even temperature — about 65° to 68° — and the air should be kept moist
with vapor.
At the outset the bowels should be opened by a mild purge, either castor
oil or small doses of calomel, one-twelfth to one-sixth of a grain hourly until
a movement is obtained, and care should be taken throughout the attack
to secure a daily movement. The common saline fever mixture of citrate
of potash, liquor ammonii acetatis, and aromatic spirits of ammonia may be
given every two or three hours. If the disease comes on abruptly with high
fever, minim or minim and a half doses of the tincture of aconite may be
given with it. The pain, the distressing symptoms, and the incessant cough
often demand opium, which must of course be used with care and judgment
in the case of young children, but which is certainly not contra-indicated and
may be usefully given in the form of paregoric. Blisters are now rarely if
ever employed, and even the jacket poultice has gone out of fashion. For
the latter, however, I confess to a strong prejudice, and when lightly made
and frequently changed it undoubtedly gives great relief. Much more com-
monly we now see, both in private and in hospital practice, the jacket of
cotton-batting. Ice-poultices to the chest may be used and do good. The diet
should consist of milk, broths, and egg albumen. Milk often curds and is dis-
agreeable. Egg-white is particularly suitable and very acceptable when given
in cold water with a little sugar. It forms, indeed, an excellent medium for
the administration of the stimulants. If the pulse shows signs of failing, it is
best to begin early with brandy. As in all febrile affections of children, cold
water should be constantly at the bedside, and the child should be encour-
aged to drink freely. With these measures, in many cases the disease pro-
gresses to a favorable termination, but too often other and more serious
symptoms arise. Cough becomes more distressing, dyspnoea increases, the
ominous rattling of the mucus can be heard in the tubes, the child's color is
not so good, and there is greater restlessness. Under these circumstances
stimulant expectorants — ammonia, squills, and senega — ^may be given. To-
gether they make a very disagreeable dose for a young child, particularly with
the carbonate of ammonia. The aromatic spirits of ammonia is somewhat
better. If the carbonate is employed, it must be given in small doses, not
more than a grain to an infant of eighteen months. If the child has increas-
ing difficulty in getting up the mucus, an emetic should be given — either the
wine of ipecac, or, if necessary, tartar emetic. There is no necessity, how-
ever, to keep the child constantly nauseated. Enough should be given to cause
prompt emesis, and the benefit results in the expulsion of the mucus from
the larger tubes. In this stage, too, strychnine is undoubtedly helpful in
stimulating the depressed respiratory centre. Inhalations of oxygen may be
employed, sometimes with great benefit.
With rapid failure of the heart, loud mucous rattles in the throat, and
increasing lividity, every measure should be used to arouse the child and
excite coughing. Alternate douches of hot and cold water, electricity, and
hypodermic injections of ether may be tried. For the reduction of tempera-
ture, particularly if cerebral symptoms are prominent, there is nothing so
satisfactory as the wet pack or the cold bath. In the case of children, when
the latter is used it should be graduated, beginning with a temperature whicli
628 DISEASES OF THE RESPIRATORY SYSTEM.
is pleasantly warm and gradually reducing it to 75° or 80°. Even when the
temperature is not high, the cerebral symptoms are greatly relieved by the bath
or the pack.
m. CHRONIC INTERSTITIAL PNEUMONIA.
(Cirrliosis of the Lung — Fibroid Phthisis.)
A fibroid change may have its starting-point in the tissue about the bronchi
and blood-vessels, the interlobular septa, the alveolar walls, or in the pleura.
So diverse are the forms and so varied the conditions under which this change
occurs that a proper classification is extremely difficult. "We may recognize,
however, two chief forms — the locals involving only a limited area of the lung
substance, and the diffuse, invading either both lungs or an entire organ.
Etiology. — Local fibroid change in the lungs is common. It is a constant
accompaniment of tubercle, in the evolution of which interstitial changes play
a very important role. In tumors, abscess, gummata, hydatids, and emphy-
sema it also occurs. Fibroid processes are frequently met with at the apices of
the lung and may be due either to a limited healed tuberculosis, to fibroid
induration in consequence of pigment, or, in a few instances, may result from
thickening of the pleura.
Diffuse ixterstitial pxeuiloxia is met with : 1. As a sequence of acute
fibrinous pneumonia. Although extremely rare, this is recognized as a possible
termination. From unknown causes resolution fails to take place. Organiza-
tion goes on in the fibrinous plugs "wdthin the air-cells and the alveolar walls
become greatly thickened by a new growth, first of nuclear and subsequently
of fibrillated connective tissue. Macroscopically there is produced a smooth,
gra}dsh, homogeneous tissue which has the peculiar translucency of all new-
formed connective tissue. This has been called gray induration. A majority
of the cases terminate within a few months, but instances which have been fol-
lowed from the outset are very rare.
2. Chronic Broncho-Pneumonia. — The relation of broncho-pneumonia to
cirrhosis of the lung has been specially studied by Charcot, who states that it
may follow the acute or subacute form of this disease, particularly in children.
The fibrosis extends from the bronchi, which are usually found dilated. Bron-
chiectasis itself may be followed by fibrosis of the lung. The alveolar walls
are thickened and the lobules converted into firm grayish masses, in which
there is no trace of normal lung tissue. This process may go on and involve
an entire lobe or even the whole lung. Many of these cases are tuberculous
from the outset.
3. Meurogenous Interstitial Pneumonia. — Charcot applies this term to
that form of cirrhosis of the lung which follows invasion from the pleura.
Doubt has been expressed by some winters whether this really occurs. While
Wilson Fox is probably correct in questioning whether an entire lung can
become cirrhosed by the gradual invasion from the pleura, there can be no
doubt that there are instances of primitive dry pleurisy, which, as Sir Andrew
Clark has pointed out. gradually compresses the lung and at the same time
leads to interstitial cirrhosis. This may be due in part to the fibroid change
which follows prolonged compression. In some cases there seems to be a dis-
DISEASES OF THE LUNGS. 629
tinct connection between the greatly thickened pleura and the dense strands
of fibrous tissue passing from it into the lung substance. Instances occur in
which one lobe or the greater part of it presents, on section, a mottled appear-
ance, owing to the increased thickness of the interlobar septa — a condition
which may exist without a trace of involvement of the pleura. In many other
eases, however, the extension seems to be so definitely associated with pleurisy
that there is no doubt as to the causal connection between the two processes.
In these instances the lung is removed with great difficulty, owing to the thick-
ness and close adhesion of the pleura to the chest wall.
4. Chronic interstitial pneumonia, due to inhalation of dust, which is
considered in a separate section.
5. Syphilis of the lung presents the features of a chronic fibrosis of the
organ (see p. 273).
6. Indurative changes in the lung may follow the compression by aneurism
or new growth or the irritation of a foreign body in a bronchus.
Morbid Anatomy. — There are two chief forms, the massive or lobar and
the insular or broncho-pneumonic form. In the massive type the disease is
unilateral ; the chest of the affected side is sunken, deformed, and the shoulder
much depressed. On opening the thorax the heart is seen drawn far over
to the affected side. The unaffected lung is emphysematous and covers the
greater portion of the mediastinum. It is scarcely credible in how small a
space, close to the spine, the cirrhosed lung may lie. The adhesions between
the pleural membranes may be extremely dense and thick, particularly in
the pleurogenous cases; but when the disease has originated in the lung there
may be little thickening of the pleura. The organ is airless, firm, and hard.
It strongly resists cutting, and on section shows a grayish fibroid tissue of
variable amonntj through which pass the blood-vessels and bronchi. The latter
may be either slightly or enormously dilated. There are instances in which
the entire lung is converted into a series of bronchiectatic cavities and the
cirrhosis is apparent only in certain areas or at the root. The tuberculous
cases can usually be differentiated by the presence of an apical cavity, not
bronchiectatic, often large, and the other lung almost invariably shows tuber-
culous lesions. Aneurisms of the pulmonary artery are not infrequent in the
cavities. The other lung is always greatly enlarged and emphysematous. The
heart is hypertrophied, particularly the right ventricle, and there may be
marked atheromatous changes in the vessels. An amyloid condition of the
viscera is found in some cases.
In the broncho-pneumonic form the areas are smaller, often centrally
placed, and most frequently in the lower lobes. They are deeply pigmented,
show dilated bronchi, and when multiple are separated by emphysematous
lung tissue.
A reticular form of fibrosis of the lung has been described by Percy Kidd
and W. McCollum, in which the lungs are intersected by grayish fibroid
strands following the lines of the interlobular septa.
Symptoms and Course. — The disease is essentially chronic, extending over
a period of many years, and when once the condition is established the health
may be fairly good. In a well-marked case the patient complains only of his
chronic cough, perhaps a slight shortness of breath. In other respects he is
quite well, and is usually able to do light work. The cases are commonly
630 DISEASES OF THE RESPIRATORY SYSTEM.
regarded as phthisical, though there may be scarcely a symptom of that affec-
tion except the cough. There are instances, however, of fibroid phthisis which
camiot be distinguished from cirrhosis of the lung except by the presence of
tubercle bacilli in the expectoration. As the bronchi are usually dilated, the
symptoms and physical signs may be those of bronchiectasis. The cough is
paroxysmal and the expectoration is generally copious and of a muco-purulent
or sero-purulent nature. It is sometimes fetid. Hajmorrhage is by no means
infrequent, and occurred in more than one-half of the cases anal3^zed by
Bastian. Walking on the level and in the ordinary affairs of life the patient
may show no shortness of breath, but in the ascent of stairs and on exertion
there may be d^^spnoea.
Physical Sigxs. — Inspection. — The affected side of the chest is immo-
bile, retracted, and shrunken, and contrasts in a striking way with the volu-
minous healthy one. The intercostal spaces are obliterated and the ribs may
even overlap. The shoulder is drawn down and from behind it is seen that
the spine is bowed. The muscles of the shoulder-girdle are wasted. The heart
is greatly displaced, being drawn over by the shrinkage of the lung to the
affected side. When the left lung is affected there may be a large area of
visible impulse in the second, third, and fourth interspaces. Mensuration
shows a great diminution in the affected side, and with the saddle-tape the
expansion may be seen to be negative. The percussion note varies with the
condition of the bronchi. It may be absolutely flat, particularly at the base
or at the apex. In the axilla there may be a flat t}Tapany or even an am-
phoric note over a large sacculated bronchus. On the opposite side the per-
cussion note is usually hj-perresonant. On auscultation the breath-sounds have
either a cavernous or amphoric quality at the apex, and at the base are feeble,
with mucous, bubbling rales. The voice-sounds are usually exaggerated.
Cardiac murmurs are not uncommon, particularly late in the disease, when
the right heart fails. These are, of course, the physical signs of the disease
when it is well established. They naturally vary considerably, according to
the stage of the process. The disease is essentially chronic, and may persist
for fifteen or twenty years. Death occurs sometimes from hemorrhage, more
commonly from gradual failure of the right heart with dropsy, and occasion-
ally from amyloid degeneration of the organs.
Diagnosis. — The diagnosis is never difficult. It may be impossible to say,
without a clear liistory, whether the origin is pleuritic or pneumonic. Between
cases of this kind and fibroid phthisis it is not always easy to discriminate, as
the conditions may be almost identical. When tuberculosis is present, how-
ever, even in long-standing cases, bacilli are usually present in the sputa, and
there may be signs of disease in the other lung.
Treatment. — It is only for an intercurrent affection or for an aggravation
of the cough that the patient seeks relief. Xothing can be done for the con-
dition itself. When possible the patient should live in a mild climate, and
should avoid exposure to cold and damp. A distressing feature in some cases
is the putrefaction of the contents of the dilated tubes, for which the same
measures may be used as in fetid bronchitis.
DISEASES OF THE LUNGS, 631
rV. PNEUMONOKONIOSIS.
Definition. — Under this term, introduced by Zenker, are embraced those
forms of fibrosis of the lung due to the inhalation of dusts in various occupa-
tions. They have received various names, according to the nature of the in-
haled particles — antliracosis, or coal-miner's disease; siderosis, due to the
inhalation of metallic dusts, particularly iron; clialicosis, due to the inhala-
tion of mineral dusts, producing the so-called stone-cutter's phthisis, or the
" grinder's rot " of the Sheffield workers.
Etiology. — The dust particles inhaled into the lungs are dealt with exten-
sively by the ciliated epithelium and by the phagocytes, which exist normally
in the respiratory organs. The ordinary mucous corpuscles take in a large
number of the particles, which fall upon the trachea and main bronchi. The
cilia sweep the mucus out to a point from which it can be expelled by cough-
ing. It is doubtful if the particles ever reach the air-cells, but the swollen
alveolar cells (in which they are in numbers) probably pick them up on the
way. The mucous and the alveolar cells are the normal respiratory scavengers.
In dwellers in the country, in which the air is pure, they are able to prevent
the access of dust particles to the lung tissue, so that even in adults these
organs present a rosy tint, very different from the dark, carbonized appear-
ance of the lungs of dwellers in cities. When the impurities in the air are
very abundant, a certain proportion of the dust particles escapes these cells
and penetrates the mucosa, reaching the lymph spaces, where they are attacked
at once by the cells of the connective-tissue stroma, which are capable of
ingesting and retaining a large quantity. In coal-miners, coal-heavers, and
others whose occupations necessitate the constant breathing of a very dusty
atmosphere even these forces are insufficient. Vansteenberghe and Grysez
have demonstrated that pulmonary anthracosis may be induced by passing
an emulsion of china ink into the stomach of an animal through a catheter.
From a long series of experiments they conclude that anthracosis is due to
the intestinal absorption of carbon particles arrested in the nose and pharynx,
and then swallowed. Their experiments further show that both the tracheal
and intestinal routes are used — through the former the particles reach the
bronchi and external portions of the alveoli, through the latter the parenchyma
of the lung. Occasionally in anthracosis the carbon grains reach the general
circulation, and the coal dust is found in the liver and spleen. As Weigert
has shown, this occurs when the densely pigmented bronchial glands closely
adhere to the pulmonary veins, through the walls of which the carbon particles
pass to the general circulation. The lung tissue has a remarkable tolerance
for these particles; but by constant exposure a limit is reached, and there is
brought about a very definite pathological condition, an interstitial sclerosis.
In coal-miners this may occur in patches, even before the lung tissue is uni-
formly infiltrated with the dust. In others it appears only after the entire
organs have become so laden that they are dark in color, and an ink-like
juice flows from the cut surface. The lungs of a miner may be black through-
out and yet show no local lesions and be everywhere crepitant.
Morbid Anatomy. — The particles of carbon are found deposited in large
numbers in the follicxilar cords of the tracheal and bronchial glands and
632 DISEASES OF THE RESPIRATORY SYSTEM.
of the peri-bronchial and peri-arterial lymph nodules, and in these they finally
excite proliferation of the connective-tissue elements. It is by no means un-
common to find in persons whose lungs are only moderately carbonized the
bronchial glands sclerosed and hard. In anthracosis the fibroid changes usu-
ally begin in the peri-bronchial lymph tissue, and in the early stage of the
process the sclerosis may be largely confined to these regions. A Nova Scotian
miner, aged thirty-six, died under my care, at the Montreal General Hospital,
of black small-pox, after an illness of a few days. In his lungs (externally
coal-black) there were round and linear patches ranging in size from a pea
to a hazel-nut, of an intensely black color, airless and firm, and surrounded
by a crepitant tissue, slate-gray in color. In the centre of each of these areas
was a small bronchus. Many of them were situated just beneath the pleura,
and formed typical examples of limited fibroid broncho-pneumonia. In addi-
tion there is usually thickening of the alveolar walls, particularly in certain
areas. By the gradual coalescence of these fibroid patches large portions of
the lung may be converted into firm areas of cirrhosis, grayish-black in the
case of the coal-miner, steel-gray in the case of the stone-worker. In the
case of a Cornish miner, aged sixty-three, who died under my care, one of
these fibroid areas measured 18 by 6 cm. and 4.5 cm. in depth.
A second important factor in these cases is chronic bronchitis, which is
present in a large proportion and really causes the chief symptoms. A third
is the occurrence of emphysema, which is almost invariably associated with
long-standing cases of pneumonokoniosis. With the changes so far described,
unless the cirrhotic area is unusually extensive, the case may present the
features of chronic bronchitis with emphysema, but finally another element
comes into play. In the fibroid areas softening occurs, probably a process of
necrosis similar to that by which softening is produced in fibro-myomata of
the uterus. At first these are small and contain a dark liquid. Charcot calls
them ulceres du poumon. They rarely attain a large size unless a communica-
tion is formed with the bronchus, in which case they may become converted
into suppurating cavities.
Anthracosis and Tuberculosis. — In the Pennsylvania anthracite district
tuberculosis is relatively less common among the miners, the figures for
ten years at Scranton for male adults being 3.37 per cent in mine workers, 9.97
per cent in those of other occupations (Wainwright). Goldman in Germany,
Oliver and Trotter in England, all agree upon the comparative rarity of tuber-
culosis among coal miners. Though this may be attributed in part to the
improved ventilation of the mines, it has also probably something to do
with the less favorable soil offered to the bacilli in a lung infiltrated with
coal dust.
The siderosis induced by the oxide of iron causes an interstitial pneumonia
similar to anthracosis. Workers in brass and in bronze are liable to a like
affection.
Chalicosis, due to the deposit of particles of silex and alumina, is found
in the makers of mill-stones, particularly the French mill-stones, and also in
knife and axe grinders and stone-cutters. Anatomically, this form is char-
acterized by the production of nodules of various sizes, which are cut with the
greatest difficulty and sometimes present a curious grayish, even glittering,
crystalloid appearance.
DISEASES OF THE LUNGS. 633
Workers in flax and in cotton, and grain-shovellers are also subject to
these chronic interstitial changes in the lungs. In all these occupations, as
shown by CIreenhow, to whose careful studies we owe so much of our knowl-
edge of these diseases, the condition of the lung may ultimately be almost
identical.
Symptoms. — The symptoms do not come on until the patient has worked
for a variable number of years in the dusty atmosphere. As a rule there are
cough and failing health for a prolonged period of time before complete disa-
bility. The coincident emphysema is responsible in great part for the short-
ness of breath and wheezy condition of these patients. The expectoration is
usually muco-purulent, often profuse, and in anthracosis very dark in color —
the so-called "black spit," while in chalicosis there may be seen under the
microscope the bright angular particles of silica.
Even when there are physical signs of cavity, tubercle bacilli are not neces-
sarily, and indeed in my experience are not usually present. It is remarkable
for how long a time a coal-miner may continue to bring up sputum laden with
coal particles even when there are signs only of a chronic bronchitis. Many
of the particles are contained in the cells of the alveolar epithelium. In these
instances it appears that an attempt is made by the leucocytes to rid the lungs
of some of the carbon grains.
The diagnosis of the condition is rarely difficult; the expectoration is usu-
ally characteristic. It must always be borne in mind that chronic bronchitis
and emphysema form essential parts of the process and that in late stages
there may be tuberculous infection.
The treatment of the condition is practically that of chronic bronchitis
and emphysema.
V. EMPHYSEMA.
Definition. — The condition in which the infundibular passages and the
alveoli are dilated and the alveolar walls atrophied.
A practical division may be made into compensatory, hypertrophic, and
atrophic forms, the acute vesicular emphysema, and the interstitial forms.
The last two do not in reality come under the above definition, but for con-
venience they may be considered here.
I. Compensatory Emphysema.
Whenever a region of the lung does not expand fully in inspiration, either
another portion of the lung must expand or the chest wall sink in order to
occupy the space. The former almost invariably occurs. We have already
mentioned that in broncho-pneumonia there is a vicarious distention of the
air- vesicles in the adjacent healthy lobules, and the same happens in the
neighborhood of tuberculous areas and cicatrices. In general pleural adhe-
sions there is often compensatory emphysema, particularly at the anterior
margins of the lung. The most advanced example of this form is seen in
cirrhosis, when the unaffected lung increases greatly in size, owing to disten-
tion of the air-vesicles. A similar though less marked condition is seen in
extensive pleurisy with effusion and in pneumothorax.
At first, this distention of the air-vesicles is a simple physiological process
42
634 DISEASES OF THE RESPtRATORY SYSTEM.
and the alveolar T^^alls are stretelied but not atrophied. Ultimately, however,
in many cases they waste and the contiguous air-cells fuse, producing true
emphysema.
II. Hypekteophic Emphysema.
The large-lunged emphysema of Jenner, also known as substantive or
idiopathic emph3'sema, is a well-marked clinical affection, characterized by
enlargement of the lungs, due to distention of the air-cells and atrophy
of their walls, and clinically by imperfect aeration of the blood and more or
less marked dyspnoea.
Etiology. — Emphysema is the result of persistently high intra-alveolar
tension acting upon a congenitally weak lung tissue. Strongly in favor of
the view that the nutritive change in the air-cells is the primary factor, is the
markedly hereditary character of the disease and the frequency with which it
starts early in life. To James Jackson, Jr., of Boston, we owe the first obser-
vations on the hereditary character of emphysema. Working under Louis' di-
rection, he found that in 18 out of 28 cases one or both parents were affected.
In childhood, it may follow recurring asthmatic attacks due to adenoid
vegetations. It may occur, too, in several members of the same family. We
are still ignorant as to the nature of this congenital pulmonary weakness.
Cohnheim thinks it probably due to a defect in the development of the elastic-
tissue fibres — a statement which is borne out by Eppinger's observations.
Heightened pressure within the air-cells may be due to forcible inspira-
tion or expiration. Much discussion has taken place as to the part played by
these two acts in the production of the disease. The inspiratory theory was
advanced by Laennec and subsequently modified by Gairdner, who held that
in chronic bronchitis areas of collapse were induced, and compensatory dis-
tention took place in the adjacent lobules. This unquestionably does occur
in the vicarious or compensatory emphysema, but it probably is not a factor
of much moment in the form now under consideration. The expiratory theory,
which was supported by Mendelssohn and Jenner, accounts for the condition
in a much more satisfactor}'- way. In all straining efforts and violent attacks
of coughing, the glottis is closed and the chest walls are strongly compressed
by muscular efforts, so that the strain is thrown upon those parts of the lung
least protected, as the apices and the anterior margins, in which we always
find the emphysema most advanced. The sternum and costal cartilages grad-
ually yield to the heightened intrathoracic pressure and are, in advanced cases,
pushed forward, giving the characteristic rotundity to the thorax.
Freuivid's Theory. — A primary disease of the costal cartilages — a chronic
hyperplasis with premature ossification is believed to bring about gradually
a state of rigid dilatation of the chest, to which the emphysema is secondary.
Eecent observations make it probable that there is a group of cases in which
such changes occur in young persons, particularly in the cartilages of the first
three ribs. Xiemeyer says that he had met with a few such cases, and there
have been reported recently instances in which the cartilages increased in size
and stood out prominently. For such a condition what is now called Freund's
operation (of resection) would be indicated.
Of other etiological factors occupation is the most important. The dis-
ease is met with in players on wind instruments, in glass-blowers, and in
DISEASES OF THE LUNGS. 635
occupations necessitating heavy lifting or straining. Whooping-cough and
bronchitis play an important role^ not so much in the changes which they
induce in the bronchi as in consequence of the prolonged attacks of
coughing.
Morbid Anatomy. — The thorax is capacious, usually barrel-shaped, g,nd
the cartilages are calcified. On removal of the sternum, the anterior medias-
tinum is found completely occupied by the margins of the lungs, and the
pericardial sac may not be visible. The organs are very large and have lost
their elasticity, so that they do not collapse either in the thorax or when placed
on the table. The pleura is pale and there is often an absence of pigment,
sometimes in patches, termed by Yhchow albinism of the lung. To the touch
they have a peculiar, downy, feathery feel, and pit readily on pressure. This
is one of the most marked features. Beneath the pleura greatly enlarged air-
vesicles may be readily seen. They vary in size from .5 to 3 mm., and irregu-
lar bullas, the size of a walnut or larger, may project from the free margins.
The best idea of the extreme rarefaction of the tissue is obtained from sec-
tions of a lung distended and dried. At the anterior margins the structure
may form an irregular series of air-chambers, resembling the frog's lung. On
careful inspection with the hand-lens, remnants of the interlobular septa or
even of the alveoli may be seen on these large emphysematous vesicles. Though
general, the distention is more marked, as a rule, at the anterior margins, and
is often specially marked at the inner surface of the lobe near the root, where
in extreme cases air-spaces as large as a hen's egg may sometimes be found.
Microscopically there is seen atrophy of the alveolar walls, by which is pro-
duced the coalescence of neighboring air-cells. In this process the capillary
network disappears before the walls are completely atrophied. The loss of
the elastic tissue is a special feature. It is stated, indeed, that in certain
cases there is a congenital defect in the development of this tissue. The epi-
thelium of the air-cells undergoes a fatty change, but the large distended air-
spaces retain a pavement layer.
The bronchi show important changes. In the larger tubes the mucous
membrane may be rough and thickened from chronic bronchitis; often the
longitudinal lines of submucous elastic tissue stand out prominently. In
the advanced cases many of the smaller tubes are dilated, particularly when,
in addition to emphysema, there are peri-bronchial fibroid changes. Bron-
chiectasis is not, however, an invariable accompaniment of emphysema, but,
as Laennec remarks, it is difficult to understand why it is not more common.
Of associated morbid changes the most important are found in the heart.
The right chambers are dilated and hypertrophied, the tricuspid orifice is
large, and the valve segments are often thickened at the edges. In advanced
cases the cardiac hypertrophy is general. The pulmonary artery and its
branches may be wide and show marked atheromatous changes.
The changes in the other organs are those commonly associated with pro-
• longed venous congestion. Pneumothorax may follow the rupture of an em-
phj^sematous bleb.
Symptoms. — The disease may be tolerably advanced before any special
symptoms occur. A child, for instance, may be somewhat short of breath on
going up-stairs or may be unable to run and play as other children without
great discomfort; or, perhaps, has attacks of slight lividity. Doubtless much
636 DISEASES OF THE RESPIRATORY SYSTEM.
depends upon the completeness of cardiac compensation. When this is per-
fect^ there may be no special interruption of the pulmonary circulation and,
except with violent exertion, there is no interference with the aeration of the
blood. In well-marked cases the following are the most important symptoms :
Dyspnoea^ which may be felt only on slight exertion, or may be persistent, and
aggravated by intercurrent attacks of bronchitis. The respirations are often
harsh and wheez}^ and expiration is distinct^ prolonged.
Cyanosis of an extreme grade is more common in emphysema than in
other affections with the exception of congenital heart-disease. So far as I
know it is the only disease in which a patient may be able to go about and
even to walk into the hospital or consulting-room with a lividity of startling
intensity. The contrast between the extreme cyanosis and the comparative
comfort of the patient is very striking. In other affections of the heart and
lungs associated with a similar degree of cyanosis the patient is invariably in
bed and usually in a state of orthopnoea. One condition must be here referred
to, viz., the extraordinary cyanosis in cases of poisoning by aniline products,
which is in most part due to the conversion of the hsemoglobin into methtemo-
globin.
Bronchitis with associated cough is a frequent symptom and often the
direct cause of the pulmonary distress. The contrast between emphysematous
patients in the winter and summer is marked in this respect. In the latter
they may be comfortable and able to attend to their work, but with the cold
and changeable weather they are laid up with attacks of bronchitis. Finally,
in fact, the two conditions become inseparable and the patient has persistently
more or less cough. The acute bronchitis may produce attacks not unlike
asthma. In some instances this is true spasmodic asthma, with which emphy-
sema is frequently associated.
As age advances, and with successive attacks of bronchitis, the condition
grows slowly worse. In hospital practice it is common to admit patients over
sixty with well-marked signs of advanced emphysema. The affection can
generall}^ be told at a glance — the rounded shoulders, barrel chest, the thin
yet oftentimes muscular form, and sometimes, I think, a very characteristic
facial expression.
There is another group, however, of younger patients from twenty-five to
forty years of age who, winter after winter, have attacks of intense cyanosis in
consequence of an aggravated bronchial catarrh. On inquiry we find that these
patients have been short-breathed from infancy, and they belong, I believe,
to a category in which there has been a primary defect of structure in the
lung tissue.
Physical Signs. — Inspection. — The thorax is markedly altered in shape;
the antero-posterior diameter is increased and may be even greater than the
lateral, so that the chest is barrel-shaped. The appearance is somewhat as if
the chest was in a permanent inspiratory position. The sternum and costal
cartilages are prominent. The lower zone of the thorax looks large and the-
intercostal spaces are much widened, particularly in the hypochondriac regions.
The sternal fossa is deep, the clavicles stand out with great prominence, and
the neck looks shortened from the elevation of the thorax and the sternum.
A zone of dilated venules may be seen along the line of attachment of the dia-
phragm. Though this is common in emphysema, it is by no means peculiar
DISEASES OF THE LUNGS. 637
to it or indeed to any special affection. Andrew, of Bartholomew's Hospital,
and, according to Duckworth, Laycock called attention to it.
The curve of the spine is increased and the back is remarkably rounded,
so that the scapula seem to be almost horizontal. Mensuration shows the
rounded form of the chest and the very slight expansion on deep inspiration.
The respiratory movements, which may look energetic and forcible, exercise
little or no influence. The chest does not expand, but there is a general ele-
vation. The inspiratory effort is short and quick ; the expiratory movement is
prolonged. There may be retraction instead of distention in the upper abdom-
inal region during inspiration, and there is sometimes seen a transverse curve
crossing the abdomen at the level of the twelfth rib. The apex beat of the
heart is not visible, and there is usually marked pulsation in the epigastric
region. The cervical veins stand out prominently and may pulsate.
Palpation. — The vocal fremitus is somewhat enfeebled but not lost. The
apex beat can rarely be felt. There is a marked shock in the lower sternal
region and very distinct pulsation in the epigastrium. Percussion gives
greatly increased resonance, full and drum-like — what is sometimes called
hyperresonance. The note is not often distinctly tympanitic in quality. The
percussion note is greatly extended, the heart dulness may be obliterated, the
upper limit of liver dulness is greatly lowered, and the resonance may extend
to the costal margin. Behind, a clear percussion note extends to a much lower
level than normal. The level of splenic dulness, too, may be lowered.
On auscultation the breath-sounds are usually enfeebled and may be
masked by bronchitic rales. The most characteristic feature is the prolonga-
tion of the expiration, and the normal ratio may be reversed — 4 to 1 instead
of 1 to 4. It is often wheezy and harsh and associated with coarse rales and
sibilant rhonchi. It is said that in interstitial emphysema there may be a
friction sound heard, not unlike that of pleurisy. The heart-sounds are usu-
ally feeble but clear; in advanced cases, when there is marked cyanosis, a
tricuspid regurgitant murmur may be heard. Accentuation of the pulmonary
second sound may be present.
Course. — The course of the disease is slow but progressive, the recurring
attacks of bronchitis aggravating the condition. Death may occur from inter-
current pneumonia, either lobar or lobular, and dropsy may supervene from
cardiac failure. Occasionally death results from overdistention of the heart,
with extreme cyanosis. Duckworth has called attention to the occasional
occurrence of fatal haemorrhage in emphysema. In an old emphysematous
patient at the Montreal General Hospital death followed the erosion of a main
branch of the pulmonary artery by an ulcer near the bifurcation of the trachea.
Treatment. — Practicall}^, the measures mentioned in connection with bron-
chitis should be employed. In children with asthma and emphysema the nose
should be carefully examined. No remedy is known which has any influence
over the progress of the condition itself. Bronchitis is the great danger of
these patients, and therefore when possible they should live in an equable
climate. The cases do well in southern California and in Egypt. In conse-
quence of the venous engorgement they are liable to gastric and intestinal dis-
turbance, and it is particularly important to keep the bowels regulated and to
avoid flatulency which often seriously aggravates the dyspnoea. Patients who
come into the hospital in a state of urgent dyspnoea and lividity, with great
638 DISEASES OF THE RESPIRATORY SYSTEM.
engorgement of the veins, particularly if the)^ are young and vigorous, should
be bled freely. Inhalation of oxygen may be used. Strychnine will be found
specially useful. Breathing of compressed air in a pneumatic cabinet gives
temporary relief. Eesection of the first costal cartilage or of the first three
cartilages on either side has been practised (Freund's operation). It is not
likely to be of any benefit in the aged in whom the condition is established,
but in a special group in the young in which the primary trouble appears to
be in the cartilages — what has been called Freund's Disease — the operation
may be tried, though it is not without risks.
III. Atrophic Emphysema.
A senile change, called by Sir William Jenner small-lunged emphysema, is
really a primary atrophy of the lung, coming on in advanced life, and scarcely
constitutes a special affection. It occurs in " withered-looking old persons "
who ma}" perhaps have had a winter cough and shortness of breath for years.
In striking contrast to the essential hypertrophic emphysema, the chest is small
and the ribs obliquely placed. The thoracic muscles are usually atrophied.
The lung presents a remarkable appearance, being converted into a series of
large vesicles, on the walls of which the remnants of air-cells may be seen.
IV. Acute Yesiculae Emphysema.
TTlien death occurs from bronchitis of the smaller tubes, when strong
inspiratory efforts have been made, the lungs are large in volume and the air-
cells are much distended. Clinicall}^, this condition may occur rapidly in
cases of cardiac asthma and angina pectoris. The area of pulmonary reso-
nance is much increased, and on auscultation there are heard everywhere
piping rales and prolonged expiration. A similar condition may follow pres-
sure on the vagi.
V. Interstitial Emphysema.
Beads of air are seen in the interlobular and subpleural tissue, sometimes
forming large bulls beneath the pleura. A rare event is rupture close to the
root of the lung, and the passage of air along the trachea into the subcuta-
neous tissues of the neck. After tracheotomy just the reverse may occur and
the air may pass from the tracheotomy wound along the windpipe and bronchi
and appear beneath the surface of the pleura. From this interstitial emphy-
sema spontaneous pneumothorax may arise in healthy persons.
VI. GANGRENE OF THE LUNG.
Etiology. — Gangrene of the lung is not an affection per se, but occurs in
a variety of conditions when necrotic areas undergo putrefaction. It is not
easy to say why sphacelus should occur in one case and not in another, as
the germs of putrefaction are always in the air-passages, and yet necrotic
territories rarely become gangrenous. Total obstruction of a pulmonary
artery, as a rule, causes infarction, and the area shut off does not often,
though it may, sphacelate. Another factor would seem to be necessary —
probably a lowered tissue resistance, the result of general or local causes. It
DISEASES OF THE LUNGS. 639
is met A\dth (1) as a sequence of lobar pneumonia. This rarely occurs in a
previously healthy person — more commonly in the debilitated or in the dia-
betic subject, (3) Gangrene is very prone to follow the aspiration pneumonia,
since the foreign particles rapidly undergo putrefactive changes. Of a similar
nature are the cases of gangrene due to perforation of cancer of the oesophagus
into the lung or into the bronchus. (3) The putrid contents of a bronchiec-
tatic, more commonly of a tuberculous, cavity may excite gangrene in the
neighboring tissues. The pressure bronchiectasis following aneurism or tumor
may lead to extensive sloughing. (4) Gangrene may follow simple embolism
of the pulmonary artery. More commonly, however, the embolus is derived
from a part which is mortified or comes from a focus of bone disease. In
typhus and in typhoid fever gangrene of the lung may follow thrombosis of one
of the larger branches of the pulmonary artery. A case occurred in my wards
in October, 1897, in connection with a typhoid septicaemia. Typhoid bacilli
were isolated from the lung. Lastly, gangrene of the lung may occur in con-
ditions of debility during convalescence from protracted fever — occasionally,
indeed, without our being able to assign any reasonable cause.
Morbid Anatomy. — Laennec, who first accurately described pulmonary
gangrene, recognized a diffuse and a circumscribed form. The former, though
rare, is sometimes seen in connection with pneumonia, more rarely after oblit-
eration of a large branch of the pulmonary artery. It may involve the greater
part of a lobe, and the lung tissue is converted into a horribly offensive green-
ish-black mass, torn and ragged in the centre. In the circumscribed form there
is well-marked limitation between the gangrenous area and the surrounding tis-
sue. The focus may be single or there may be two or more. The lower lobe
is more commonly affected than the upper, and the peripheral more than the
central portion of the lung. A gangrenous area is at first uniformly greenish-
brown in color ; but softening rapidly takes place with the formation of a cavity
with shreddy, irregular walls and a greenish, offensive fluid. The lung tissue
in the immediate neighborhood shows a zone of deep congestion, often consoli-
dation, and outside this an intense oedema. In the embolic cases the plugged
artery can sometimes be found. When rapidly extending, vessels may be
opened and a copious haemorrhage ensue. Perforation of the pleura is not
uncommon. The irritating decomposing material usually excites the most
intense bronchitis. Embolic processes are not infrequent. There is a remark-
able association in some cases between circumscribed gangrene of the lung and
abscess of the brain. It has been referred to under the section on bron-
chiectasis.
Symptoms and Course. — Usually definite symptoms of local pulmonary
disease precede the characteristic features of gangrene. These, of course, are
very varied, depending on the nature of the trouble. The sputum is very char-
acteristic. It is intensely fetid — usually profuse — and, if expectorated into
a conical glass, separates into three layers — a greenish-brown, heavy sediment ;
an intervening thin liquid, which sometimes has a greenish or a brownish tint ;
and, on top, a thick, frothy layer. Spread on a glass plate, the shreddy dehris
of lung tissue can readily be picked out. Even large fragments of lung may
be coughed up. Robertson, of Onancock, Va., sent me one several centimetres
in length, which had been expectorated by a lad of eighteen, who had severe
gangrene and recovered. Microscopically, elastic fibres are found in abun-
640 DISEASES OF THE RESPIRATORY SYSTEM.
dance, with granular matter, pigment grains, fatty crystals, bacteria, and
leptothrix. It is stated that elastic tissue is sometimes absent, but I have
never met with such an instance. The peculiar plugs of sputum which occur
in bronchiectasis are not found. Blood is often present, and, as a rule, is much
altered. The sputum has, in a majority of the cases, an intensely fetid odor,
which is communicated to the breath and may permeate the entire room. It
is much more offensive than in fetid bronchitis or in abscess of the lung. The
fetor is particularly marked when there is free communication between the
gangrenous cavities and the bronchi. On several occasions I have found, post
mortem, localized gangrene, which had been unsuspected during life, and in
which there had been no fetor of the breath.
The physical signs, when extensive destruction has occurred, are those
of cavity, but the limited circumscribed areas may be difficult to detect.
Bronchitis is always present.
Among the general symptoms may be mentioned fever, usually of moderate
grade ; the pulse is rapid, and very often the constitutional depression is severe.
But the only special features indicative of gangrene are the sputa and the
fetor of the breath. The patient generally sinks from exhaustion. Fatal
hemorrhage may ensue.
Treatment. — The treatment of gangrene is very unsatisfactory. The indi-
cations, or course, are to disinfect the gangrenous area, but this is often impos-
sible. An antiseptic spray of carbolic acid may be employed. A good plan
is for the patient to use over the mouth and nose an inhaler, which may be
charged with a solution of carbolic acid or with guaiacol; the latter drug has
also been used hypodermically, with, it is said, happy results in removing the
odor. If the signs of cavity are distinct an attempt should be made to cleanse
it by direct injections of an antiseptic solution. If the patient's condition is
good and the gangrenous region can be localized, surgical interference may be
indicated. Successful cases have been reported. The general condition of
the patient is always such as to demand the greatest care in the matter of
diet and nursing,
VII. ABSCESS OF THE LUNG.
Etiology. — Suppuration occurs in the lung under the following conditions :
(1) As a sequence of inflammation, either lobar or lobular. Apart from the
purulent infiltration this is unquestionably rare, and even in lobar pneumonia
the abscesses are of small size and usually involve, as Addison remarked, sev-
eral points at the same time. On. the other hand, abscess formation is
extremely frequent in the deglutition and aspiration forms of lobular pneu-
monia. After wounds of the neck or operations upon the throat, in suppura-
tive disease of the nose or larynx, occasionally even of the ear (Volkmann),
infective particles reach the bronchial tubes by aspiration and excite an intense
inflammation which often ends in abscess. Cancer of the oesophagus, perfo-
rating the root of the lung or into the bronchi, may produce extensive suppura-
tion. The abscesses vary in size from a walnut to an orange, and have ragged
and irregular walls, and purulent, sometimes necrotic, contents.
(2) Embolic, so-called metastatic, abscesses, the result of infective emboli,
are extremely common in pj^mia. They may be numerous and present very
DISEASES OF THE LUNGS. 641
definite characters. As a rule they are superficial, beneath the pleura, and
often wedge-shaped. At first firm, grayish-red in color, and surrounded by a
zone of intense hypersemia, suppuration soon follows with the formation of a
definite abscess. The pleura is usually covered with greenish lymph, and per-
foration sometimes takes place with the production of pneumothorax.
( 3 ) Perforation of the lung from without, lodgment of foreign bodies, and,
in' the right lung, perforation from abscess of the liver or a suppurating echino-
coccus cyst are occasional causes of pulmonary abscess.
(4) Suppurative processes play an important part in chronic pulmonary
tuberculosis, many of the symptoms of which are due to them.
Symptoms. — Abscess following pneumonia is easily recognized by an aggra-
vation of the general symptoms and by the physical signs of cavity and the
characters of the expectoration. Embolic abscesses can not often be recognized,
and the local symptoms are generally masked in the general pygemic manifes-
tations. The characters of the sputum are of great importance in determining
the presence of abscess. The odor is offensive, yet it rarely has the horrible
fetor of gangrene or of putrid bronchitis. In the pus fragments of lung tissue
can be seen, and the elastic tissue may be very abundant. The presence of this
with the physical signs rarely leaves any question as to the nature of the
trouble. Embolic cases usually run a fatal course. Eecovery occasionally
occurs after pneumonia. In a case following typhoid fever which I saw at
the Garfield Hospital, Kerr removed two ribs and found free in the pus of
a localized empyema a sequestered piece of lung, the size of the palm of the
hand, which had sloughed off clearly from the lower lobe. The patient made
a good recovery.
Medicinal treatment is of little avail in abscess of the lung. When well
defined and superficial, an attempt should always be made to open and drain
it. A number of successful cases have already been treated in this way.
VIII. NEW GROWTHS IN THE LUNGS.
Etiology and Morbid Anatomy. — While primary tumors are rare, second-
ary growths are not uncommon.
Carcinoma is the most common primary form. Endothelium and sarcoma
are less frequently met with.
The secondary growths may be of various forms. Most commonly they
follow tumors in the digestive or genito-urinary organs or on the breast; not
infrequently also tumors of the bone. There may be scirrhus, epithelioma,
colloid, melano-sarcoma, fibroma, enchondroma, or osteoma. The lungs may
be extensively involved in Hodgkin's disease.
Primary cancer or sarcoma usually involves only one lung. The second-
ary growths are distributed in both. The primary growth generally forms a
large mass, which may occupy the greater part of a lung. Necrosis and cavity
formation may occur. In the diffuse cancerous growth the condition may
resemble a tuberculous pneumonia. A miliary type of growth has been de-
scribed. Occasionally the secondary growths are solitary and confined chiefly
to the pleura. The metastatic growths are nearly always disseminated. Occa-
sionally they occupy a large portion of the pulmonary tissue. In a case of
colloid cancer secondary to cancer of the pancreas, I found both lungs volu-
642 DISEASES OF THE RESPIRATORY SYSTEM.
minous, heavy, only slightly crepitant, and occupied by circular translucent
masses, varying in size from a pea to a large walnut.
There are numerous accessory lesions in the pulmonary new growths.
There ma}' be pleurisy, either cancerous or sero-fibrinous. The efEusion may
be hemorrhagic, but in 200 cases of cancer, primary or secondary, of the
lungs and pleura analyzed by Moutard-Martin, hsemorrhagic effusion occurred
in only 12 per cent. The tracheal and bronchial glands are usually affected,
the cervical glands not infrequently, and occasionally even the inguinal.
The disease is most common in the middle period of life. The primary
cancer is much more frequent in men (73 per cent, Passler), but secondary
cancer is much more common in women. The conditions which predispose to
it are quite unknown. It is a remarkable fact that the workers in the Sclmee-
berg cobalt mines are very liable to primary cancer of the lungs. It is stated
that in this region a considerable proportion of all deaths in persons over
forty are due to this disease.
Symptoms. — The clinical features of neoplasms of the lungs are by no
means distinctive, particularly in the case of primary growths. The patient
may, indeed, as noted by Walshe, present no symptoms pointing to intra-
thoracic disease. Among the more important symptoms are pain, particularly
when the pleura is involved ; dyspnoea, which is apt to be paroxysmal when due
to pressure upon the trachea ; cough, which may be dry and painful and accom-
panied by the expectoration of a dark mucoid sputum. This so-called prime-
Juice expectoration, which was present 10 times in 18 cases of primary cancer
of the lung, was thought by Stokes to be of great diagnostic value.
In many instances there are signs of compression of the large veins, pro-
ducing lividity of the face and upper extremities, or occasionally of only one
arm. Compression of the trachea and bronchi may give rise to urgent
dyspnoea. The heart may be pushed over to the opposite side. The pneumo-
gastric and recurrent laryngeal nerves are occasionally involved in the
growth.
Physical Sigxs. — The patient, according to Walshe, usually lies on the
affected side. On inspection this side may be enlarged and immobile and the
intercostal spaces are obliterated. This is more commonly due to the effusion
than to the growth itself. The external tymph-glands may be enlarged, par-
ticularly the clavicular. The signs, on percussion and auscultation, are varied,
depending much upon the presence or absence of fluid. Signs of consolidation
are, of course, present; the tactile fremitus is absent and the breath-sounds
are usually diminished in intensity. Occasionally there is t}^ical bronchial
breathing. Among other sj^mptoms may be mentioned fever, which is present
in a certain number of cases. Emaciation is not necessarily extreme. The
duration of the disease is from six to eight months. Occasionally it runs a
very acute course, as noted by Cars well. Cases are reported in which death
occurred in a month or six weeks, and in one instance (Jaccoud) the patient
died in a week from the onset of the symptoms.
Diagnosis. — In secondary growths this is not difiicult. The occurrence
of pulmonary sjTnptoms within a year or two after the removal of a cancer
of the breast, or after the amputation of a limb for osteo-sarcoma, or the onset
of similar symptoms in connection with cancer of the liver, or of the uterus,
or of the rectum, would be extremely suggestive. In primary cases the uni-
DISEASES OF THE PLEURA. 643
lateral involvement, the anomalous character of the physical signs, the occur-
rence of prune-juice expectoration, the progressive wasting, and the secondary
involvement of the cervical glands are the important points in the diagnosis.
E. DISEASES OF THE PLEURA.
I. ACUTE PLEURISY.
Anatomically, the eases may he divided into dry or adhesive pleurisy and
pleurisy with effusion. Another classification is into primary or secondary
forms. According to the course of the disease, a division may be made into
acute and chronic pleurisy, and as it is impossible, at present, to group the
various forms etiologically, this is perhaps the most satisfactory division. The
following forms of acute pleurisy may be considered :
I. Fibrinous or Plastic Pleurisy.
In this the pleural membrane is covered by a sheeting of lymph of variable
thickness, which gives it a turbid, granular appearance, or the fibrin may
exist in distinct layers. It occurs (1) as an independent affection, following
cold or exposure. This form of acute plastic pleurisy without fluid exudate
is not common in perfectly healthy individuals. Cases are met with, however,
in which the disease sets in with the usual symptoms of pain in the side and
slight fever, and there are the physical signs of pleurisy as indicated by the fric-
tion. After persisting for a few days, the friction murmur disappears and no
exudation occurs. Union takes place between the membranes, and possibly the
pleuritic adhesions which are found in such a large percentage of all bodies
examined after death originate in these slight fibrinous pleurisies.
Fibrinous pleurisy occurs (2) as a secondary process in acute diseases of
the lung, such as pneumonia, which is always accompanied by a certain amount
of pleurisy, usually of this form. Cancer, abscess, and gangrene also cause
plastic pleurisy when the surface of the lung becomes involved. This condition
is specially associated in a large number of cases with tuberculosis. Pleural
pain, stitch in the side, and a dry cough, with marked friction sounds on aus-
cultation are the initial phenomena in many instances of phthisis. The signs
are usually basic, but Burney Yeo has recently called attention to the fre-
quency with which they occur at the apex.
II. Sero-fibrinous Pleurisy.
In a majority of cases of inflammation of the pleura there is, with the
fibrin, a variable amount of fluid exudate, which produces the condition known
as pleurisy with effusion.
Etiology. — Of 194 cases in flfteen years in my wards, there were 161 males
and 33 females. Under twenty years of age there were 20 patients; 18 were
over sixty years of age. The greatest number was in the fifth decade, 59.
Cold acts as a predisposing agent, which permits the action of various micro-
organisms. We have not yet, however, brought all the acute pleurisies into
the category of microbic affections, and the fact remains that pleurisy does
follow with great rapidity a sudden wetting or a chill. A majority of the
644 DISEASES OF THE RESPIRATORY SYSTEM.
cases are tuberculous. This view is based upon: (1) Post-mortem evidence.
Tubercles have been found in acute cases, thought to have been rheumatic or
due to cold. (2) The not infrequent presence of tuberculous lesions, often
latent, in the lung or elsewhere. (3) The character of the exudate. If coagu-
lated and the eoagulum digested and centrifugalized (Inoscopy), tubercle
bacilli are frequenth^ found. Injected into a guinea pig, in amounts of 15 cc.
or more, tuberculosis followed in 62 per cent (Eiehhorst). The cyto-diagnosis
shows that as in other tuberculous exudates the mono-nuclear leucocytes pre-
dominate. (4) The tuberculin reaction is given in a considerable percentage
of the cases. (5) The subsequent history. Of 90 eases of acute pleurisy
which had been under the observation of H. I. Bowditch between 1849 and
1879, 32 died of or had phthisis. Among 130 patients with primary pleurisy
with effusion, followed for a period of seven years by Hedges, 40 per cent
became tuberculous.
Of 300 uncomplicated cases of pleural effusion in the Massachusetts Gen-
eral Hospital, followed by E. C. Cabot, the subsequent history was ascertained
in 221 ; followed five years until death or phthisis, 117 ; well after five years, 96.
In 172 of our cases of pleurisy with effusion Hamman got reports from 88 ;
of these 48 were living and well, 30 later became tuberculous, in 2 the result
was questionable, and 8 died of other diseases. Twelve of the 88 had tubercle
bacilli in the sputum while in the hospital without discoverable pulmonary
lesion; 3 of the 12 are living and well; in 8 the signs became well marked;
one died of unkno^vn cause. Hamman has collected 562 cases (including our
ovm) in wliich the subsequent history was sought ; of these 167, 29.7 per cent,
became tuberculous.
Bacteriology of Acute Pleurisy. — From a bacteriological standpoint we may
recognize three groups of cases, caused by the tubercle bacillus, the pneumo-
coccus, and the streptococcus, respectively.
Bacillus tuberculosis is present in a very large proportion of all cases
of primary or so-called idiopathic pleurisy. The exudate is usually sterile
on cover-slips or in the culture and inoculation tests made in the ordinary
way, as the bacilli are very scanty. It has been demonstrated clearly that
a large amount of the exudate must be taken to make the test complete, either
in cultures or in the inoculation of animals. Eiehhorst found that more than
62 per cent were demonstrated as tuberculous when as much as 15 cc. of the
exudate was inoculated into test animals, while less than 10 per cent of the
cases showed tuberculosis when only 1 cc. of the exudate was used. This is a
point to which observers should pay very special attention. Le Damany has
recently in 55 primary pleurisies demonstrated the tuberculous character of
all but 4. He has used large quantities of the fluid for his inoculation
experiments.
The pneumocoecus pleurisy is almost always secondary to a focus of inflam-
mation in the lung. It may, however, be primary. The exudate is usually
purulent and the outlook is very favorable.
The streptococcus pleurisy .is the tj^ical septic form which may occur
either from direct infection of the pleura through the lung in broncho-pneu-
monia, or in cases of streptococcus pneumonia; in other instances it follows
infection of more distant parts. The acute streptococcus pleurisy is the most
serious and fatal of all forms.
DISEASES OF THE PLEURA. 645
Among other bacteria which have been found are the staphylococcus. Fried-
lander's bacillus, the typhoid bacillus, and the diphtheria bacillus.
Morbid Anatomy. — In sero-fibrinous pleurisy the serous exudate is abun-
dant and the fibrin is found on the pleural surfaces and scattered through
the fluid in the form of flocculi. The proportions of these constituents vary
a great deal. In some instances there is very little membranous fibrin; in
others it forms thick, creamy layers and exists in the dependent part of the
fluid as whitish, curd-like masses. The fluid of sero-fibrinous pleurisy is of
a lemon color, either clear or slightly turbid, depending on the number of
formed elements. In some instances it has a dark-brown color. The micro-
scopical examination of the fluid shows leucocytes, occasional swollen cells,
which may possibly be derived from the pleural endothelium, shreds of fibril-
lated fibrin, and a variable number of red blood-corpuscles. On boiling, the
fluid is found to be rich in albumin. Sometimes it coagulates spontaneously.
Its composition closely resembles that of blood-serum. Cholesterin, uric acid,
and sugar are occasionally found. The amount of the effusion varies from
"I to 4 litres. The lung in acute sero-fibrinous pleurisy is more or less com-
pressed. If the exudation is limited the lower lobe alone is atelectatic ; but in
an extensive effusion which reaches to the clavicle the entire lung will be found
lying close to the spine, dark and airless, or even bloodless — i. e., carnified.
In large exudations the adjacent organs are displaced; the liver is depressed
and the heart dislocated. With reference to the position of the heart, the fol-
lowing statements may be made: (1) Even in the most extensive left-sided
exudation there is no rotation of the apex of the heart, which in no case was
to the right of the mid-sternal line; (2) the relative position of the apex and
base is usually maintained; in some instances the apex is lifted, in others the
whole heart lies more transversely; (3) the right chambers of the heart occupy
the greater portion of the front, so that the displacement is rather a definite
dislocation of the mediastinum, with the pericardium, to the right, than any
special twisting of the heart itself; (4) the kink or twist in the inferior vena
cava described by Bartels was not present in any of my cases.
For a discussion of the physics of cardiac displacement see Calvert, Johns
Hophins Hospital Bulletin, 1907.
Symptoms. — Prodromes are not uncommon, but the disease may set in
abruptly with a chill, followed by fever and a severe pain in the side. In
very many cases, however, the onset is insidious, particularly in children and
in elderly persons. A little dyspnoea on exertion and an increasing pallor
may be the only features. Washbourn has called attention to the frequency
with which the pneumococcus pleurisy sets in with the features of pneumonia.
The pain in the side is the most distressing symptom, and is usually referred to
the nipple or axillary regions. It must be remembered, however, that pleuritic
pain may be felt in the abdomen or low down in the back, particularly when
the diaphragmatic surface of the pleura is involved. It is lancinating, sharp,
and severe, and is aggravated by cough. At this early stage, on auscultation,
sometimes indeed on palpation, a dry friction rub can be detected. The fever
.rarely rises so rapidly as in pneumonia, and does not reach the same grade.
A temperature of from 102° to 103° is an average pyrexia. It may drop to
normal at the end of a week or ten days without the appearance of any definite
change in .the physical signs, or it may persist for several weeks. The tem-
646 DISEASES OF THE RESPIRATORY SYSTEM.
perature of the affected is higher than that of the sound side. Cough is an
early symptom in acute pleurisy, but is rarely so distressing or so frequent
as in pneumonia. There are instances in which it is absent. The expectora-
tion is usually slight in amount, mucoid in character, and occasionally streaked
with blood.
At the outset there may be dyspnoea, due partly to the fever and partly
to the pain in the side. Later it results from the compression of the lung,
particularly if the exudation has taken place rapidly. When, however, the
fluid is effused slowly, one lung may be entirely compressed without inducing
shortness of breath, except on exertion, and the patient will lie quietly in bed
without evincing the slightest respiratory distress. When the effusion is large
the patient usually prefers to lie upon the affected side.
Physical Signs. — Inspection shows some degree of immobility on the
affected side, depending upon the amount of exudation ; and in large effusions
an increase in volume, which may appear to be much more than it really
is as determined by mensuration. The intercostal depressions are obliterated.
In right-sided effusions the apex beat may be lifted to the fourth interspace
or be pushed beyond the left nipple, or may even be seen in the axilla. When
the exudation is on the left side, the heart's impulse may not be visible; but
if the effusion is large it is seen in the third and fourth spaces on the right
side, and sometimes as far out as the nipple, or even beyond it.
Palpation enables us more successfully to determine the deficient move-
ments on the affected side, and the obliteration of the intercostal spaces, and
more accurately to define the position of the heart's impulse. In simple sero-
fibrinous effusion there is rarely any cfidema of the chest walls. It is scarcely
ever possible to obtain fluctuation. Tactile fremitus is greatly diminished or
abolished. If the effusion is slight there may be only enfeeblement. The
absence of the voice vibrations in effusions of any size constitutes one of the
most valuable of physical signs. In children there may be much effusion with
retention of fremitus. In rare cases the vibrations may be communicated to
the chest walls through localized pleural adhesions.
Mensuration. — With the cyrtometer, if the effusion is excessive, a differ-
ence of from half an inch to an inch, or even, in large effusions, an inch and
a half, may be found between the two sides. Allowance must be made for the
fact that the right side is naturally larger than the left. With the saddle-tape
the difference in expansion between the two sides can be conveniently measured.
Percussion. — Early in the disease, there may be no alteration in the note,
but vsdth the gradual accumulation of the fluid the resonance becomes defec-
tive, and finally gives place to absolute flatness. From day to day the gradual
increase in height of the fluid may be studied. In a pleuritic effusion
rising to the fourth rib in front, the percussion signs are usually very sug-
gestive. In the subclavicular region the attention is often aroused at once
by a tympanitic note, the so-called Skoda's resonance, which is heard perhaps
more commonly in this situation with pleural effusion than in any other con-
dition. It shades insensibly into a flat note in the lower mammary and
axillary regions. Skoda's resonance may be obtained also behind, just above
the limit of effusion. The dulness has a peculiarly resistant, wooden quality,
differing from that of pneumonia and readily recognized by skilled fingers.
It has long been known that when the patient is in the erect posture the
DISEASES OF THE PLEURA. 647
upper line of diilness is not horizontal, but is higher behind than it is in front,
forming a parabola. The curve marking the intersection of the plane of con-
tact of lung and fluid with the chest wall is known as " Ellis's line of flat-
ness," which Garland has verified clinically and by animal experiments. With
medium-sized effusions this line begins lowest behind, advances upward and
forward in a letter- S curve to the axillary region, whence it proceeds in a
straight decline to the sternum. This curve is demonstrable only wheii the
patient is in the erect position. Grocco, in 1902, called attention to the ex-
istence in pleural effusion of a triangular area of relative dulness, along the
spine, on the side opposite to the pleurisy, in width from 2 to 5 cm., and
with the apex upward. It can be demonstrated in a large majority of all
cases, particularly in the young and in thin persons. It is due to the bulg-
ing of the mediastinum, by the fluid, across the middle line, the anatomical
possibility of which has been pointed out by Calvert.
On the right side the dulness passes without change into that of the liver.
On the left side in the nipple line it extends to and may obliterate Traube's
semilunar space. If the effusion is moderate, the phenomenon of movable
dulness may be obtained by marking carefully, in the sitting posture, the upper
limit in the mammary region, and then in the recumbent posture, noting the
change in the height of dulness. This infallible sign of fluid can not always
be obtained. In very copious exudation the dulness may reach the clavicle
and even extend beyond the sternal margin of the opposite side.
Auscultation. — Early in the disease a friction rub can usually be heard,
which disappears as the fluid accumulates. It is a to-and-fro dry rub, close
to the ear, and has a leathery, creaking character. There is another pleural
friction sound which closely resembles, and is scarcely to be distinguished
from, the fine crackling crepitus of pneumonia. This may be heard at the
commencement of the disease, and also, as pointed out in 1844 by Mac-
Donnell, Sr., of Montreal, when the effusion has receded and the pleural layers
come together again.
With even a slight exudation there is weakened or distant breathing.
Often inspiration and expiration are distinctly audible, though distant, and
have a tubular quality. Sometimes only a puffing tubular expiration is heard,
which may have a metallic or amphoric quality. Loud resonant rales accom-
panying this may forcibly suggest a cavity. These pseudo-cavernous signs are
met with more frequently in children, and often lead to error in diagnosis.
Above the line of dulness the breath-sounds are usually harsh and exaggerated,
and may have a tubular quality.
The vocal resonance is usually diminished or absent. The whispered
voice is said to be transmitted through a serous and not through a purulent
exudate (Baccelli's sign). This author advises direct auscultation in the
antero-lateral region of the chest. There may, however, be intensification —
bronchophony. The voice sometimes has a curious nasal, squeaking character,
which was termed by Laennec cegophony, from its supposed resemblance to the
bleating of a goat. In typical form this is not common, but it is by no means
rare to hear a curious twang-like quality in the voice, particularly at the outer
angle of the scapula.
In the examination of the heart in cases of pleuritic effusion it is well
to bear in mind that when the apex of the heart lies beneath the sternum
648 DISEASES OF THE RESPIRATORY SYSTEM.
there may be no impulse. The determination of the situation of the organ
may rest with the position of maximum loudness of the sounds. Over the
displaced organ a systolic murmur may be heard. When the lappet of lung
over the pericardium is involved on either side there may be a pleuro-peri-
cardial friction. Emerson has looked over for me the histories of 89 cases
of acute pleurisy with effusion in which the blood counts were made before
the temperature reached normal. Only 26 had a leucocytosis between 10,000
and 15,000; one only above 15,000. In 12 of the cases the count was below
5,000. '
Course. — The course of acute sero-iibrinous pleurisy is very variable. After
persisting for a week or ten days the fever subsides, the cough and pain dis-
appear, and a slight effusion may be quickly absorbed. In cases in which
the effusion reaches as high as the fourth rib recovery is usually slower.
Many instances come under observation for the first time, after two or three
weeks' indisposition, with the fluid at a level with the clavicle. The fever
may last from ten to twenty days without exciting anxiety, though, as a rule,
in ordinary pleurisy from cold, as we say, the temperature in cases of moderate
severity is normal within eight or ten days. Left to itself the natilral tend-
ency is to resorption; but this may take place very slowly. With the absorp-
tion of the fluid there is a redux-f riction crepitus, either leathery and creaking
or crackling and rale-like, and for months, or even longer, the defective reso-
nance and feeble breathing are heard at the base. Eare modes of termination
are perforation and discharge through the lung, and externally through the
chest wall, examples of which have been recorded by Sahli.
The immediate prognosis in pleurisy with effusion is good. Of 320 cases
at St. Bartholomew's Hospital, only 6.1 per cent died before leaving the hos-
pital (Hedges).
A sero-fibrinous exudate may persist for months without change, particu-
larly in tuberculous cases, and will sometimes reaccumulate after aspiration
and resist all treatment. After persistence for more than twelve months, in
spite of repeated tapping, a serous effusion was cured by incision without
deformity of the chest (S. West). When one pleura is full and the heart
is greatly dislocated, the condition, although in a majority of cases producing
remarkably little disturbance, is not without risk. Sudden death may occur,
and its possibility under these circumstances should always be considered. I
have seen two instances — one in right and the other in left sided effusion —
both due, apparently, to syncope following slight exertion, such as getting
out of bed. In neither case, however, was the amount of fluid excessive. Weil,
who has studied carefully this accident, concludes as follows: (1) That it may
be due to thrombosis or embolism of the heart or pulmonary artery, oedema of
the opposite lung, or degeneration of the heart muscle; (2) such alleged causes
as mechanical impediment to the circulation, owing to dislocation of the heart
or twisting of the great vessels, require further investigation. Death may
occur without any premonitory symptoms.
III. Purulent Pleueist (Empyema).
Etiology. — Pus in the pleura is due to (a) infection from within, as a
rule directly from a patch of pneumonia or a septic focus due to the pneumo-
coccus or the pus organisms, in some cases a tuberculous broncho-pneumonia;
DISEASES OF THE PLEURA. 649
(6) involvement from without, as in fracture of a rib, penetrating wound,
disease of oesophagus, etc.
It frequently follows the infectious diseases, particularly scarlet fever. It
is very often latent, and due to undiscovered foci of lobar or lobular pneu-
monia. It is common in children, more in boys than in girls and between
the ages of one and five and eight and nine (Bythell).
The pneumococcus is the most common organism, then the ordinary pus
organisms and the tubercle bacilli. The pneumococcus has been found and in
rare cases the influenza bacillus, and even psorosperms.
Morbid Anatomy. — On opening an empyema post mortem, we usually find
that the effusion has separated into a clear, greenish-yellow serum above and
the thick, cream-like pus below. The fluid may be scarcely more than turbid,
with flocculi of fibrin through it. In the pneumococcus empyema the pus is
usually thick and creamy. It usually has a heavy, sweetish odor, but in some
instances — ^particularly those following wounds — it is fetid. In cases of gan-
grene of the lung or pleura the pus has a horribly stinking odor. Microscop-
ically it has the characters of ordinary pus. The pleural membranes are greatly
thickened, and present a grayish-white layer from 1 to 2 mm. in thickness. On
the costal pleura there may be erosions, and in old cases fistulous communica-
tions are common. The lung may be compressed to a very small limit, and the
visceral pleura also may show perforations.
Symptoms. — Purulent pleurisy may begin abruptly, with the symptoms
already described. More frequently it comes on insidiously in the course of
other diseases or follows an ordinary sero-fibrinous pleurisy. There may be no
pain in the chest, very little cough, and no dyspnoea, unless the side is very full.
Symptoms of septic infection are rarely wanting. If in a child, there is a grad-
ually developing pallor and weakness ; sweats occur, and there is irregular fever.
A cough is by no means constant. The leucocytes are usually much increased ;
in one fatal case they numbered 115,000 per cubic millimetre.
Physical Signs. — Practically they are those already considered in pleu-
risy with effusion. There are, however, one or two additional points to be men-
tioned. In empyema, particularly in children, the disproportion between the
sides may be extreme. The intercostal spaces may not only be obliterated, but
may bulge. ISTot infrequently there is oedema of the chest walls. The network
of subcutaneous veins may be very distinct. It must not be forgotten that in
children the breath-sounds may be loud and tubular over a purulent effusion
of considerable size. Whispered pectoriloquy is usually not heard in empyema
(Baccelli's sign). The dislocation of the heart and the displacement of the
liver are more marked in empyema than in sero-fibrinous effusion — probably, as
Senator suggests, owing to the greater weight of the fluid.
A curious phenomenon associated generally with empyema, but sometimes
occurring in the sero-fibrinous exudate, is pulsating pleurisy^, first described by
MacDonnell, Sr., of Montreal. In 95 cases collected by Sailer it was much
more frequent in males than in females. In 38 there was a tumor; that is,
empyema necessitatis. In all but one case the fluid was purulent. Pneumo-
thorax may be present. There are two groups of cases, the intrapleural pul-
sating pleurisy and the pulsating empyema necessitatis, in which there is an
external pulsating tumor. No satisfactory explanation has been offered how
the heart impulse is thus forcibly communicated through the effusion.
650 DISEASES OF THE RESPIRATORY SYSTEM.
Empyema is a chronic affection, which in a few instances terminates natu-
rally in recovery, but a majority of cases, if left alone, end in death. The fol-
lowing are some modes of natural cure: (a) By absorption of the fluid. In
small effusions this may take place gradually. The chest wall sinks. The
pleural layers become greatly thickened and enclose between them the inspis-
sated pus, in which lime salts are gradually deposited. Such a condition may
be seen once or twice a year in the post-mortem room of any large hospital.
(&) By perforation of the lung. Although in this event death may take place
rapidl}^, by suffocation, as Aretseus says, yet in cases in which it occurs grad-
ually recovery may follow. Since 1873, when I saw a case of this kind in
Traube's clinic, and heard his remarks on the subject, I have seen a number
of instances of the kind and can corroborate his statement as to the favorable
termination of many of them. Empyema may discharge either by opening into
the bronchus and forming a fistula, or, as Traube pointed out, by producing
necrosis of the pulmonary pleura, sufficient to allow the soaking of the pus
through the spongy lung tissue into the bronchi. In the first way pneumo-
thorax usually, though not always, develops. In the second way the pus is
discharged, without formation of pneumothorax. Even with a bronchial fistula
recovery is possible, (c) By perforation of the chest wall — empyema necessi-
tatis. This is by no means an unfavorable method, as many cases recover. The
perforation may occur an^'where in the chest wall, but is, as Cruveilhier re-
marked, more common in front. It may be am-^'here from the third to the
sixth interspace, usuaUy, according to Marshall, in the fifth. It may perforate
in more than one place, and there may be a fistulous communication which
opens into the pleura at some distance from the external orifice. The tumor,
when near the heart, may pulsate. The discharge may persist for years. In
Copeland's Dictionary is mentioned an instance of a Bavarian physician who
had a pleural fistula for thirteen years and enjoyed fairly good health.
An empyema may perforate the neighboring organs, the oesophagus, peri-
tonseum, pericardium, or the stomach. A remarkable sequel is a pleuro-cesoph-
ageal fistula, of which cases have been reported by A^oelcker, Thursfield, and
myself. In my case there was a fistulous communication through the chest
wall. Very remarkable cases are those which pass down the spine and along
the psoas into the iliac fossa, and simulate a psoas or lumbar abscess.
IV. Tuberculous Pleurisy.
This has already been considered (p. 308), and the symptoms and physical
signs do not require any description other than that already given in connec-
tion with the sero-fibrinous and purulent forms.
V. Other A^arieties of Pleueisy.
Haemorrhagic Pleurisy. — A bloody effusion is met with under the follow-
ing conditions: {a) In the pleurisy of asthenic states, such as cancer, Brighfs
disease, and occasionally in the malignant fevers. It is interesting to note the
frequency with which hajmorrhagic pleurisy is found in cirrhosis of the liver.
It occurred in the very patient in whom Laennec first accurately described
this disease. While this may be a simple ha?morrhagic pleurisy, in a majority
of the cases which I have seen it has been tuberculous. (6) Tuberculous pleu-
DISEASES OF THE PLEURA. 651
risy, in which the bloody effusion may result from the rupture of newly formed
vessels in the soft exudate accompanying the eruption of miliary tubercles, or
it may come from more slowly formed tubercles in a pleurisy secondary to
extensive pulmonary disease, (c) Cancerous pleurisy, whether primary or sec-
ondary, is frequently hsemorrhagic. (d) Occasionally hsemorrhagic exudation
is met with in perfectly healthy individuals, in whom there is not the slight-
est suspicion of tuberculosis or cancer. In one such case, a large, able-bodied
man, the patient was to my knowledge healthy and strong eight years after-
ward. And, lastly, it must be remembered that during aspiration the lung
may be wounded and blood in this way get mixed with the sero-fibrinous exu-
date. The condition of haBmorrhagic pleurisy is to be distinguished from
hsemothorax, due to the rupture of aneurism or the pressure of a tumor on the
thoracic veins.
Diaphragmatic Pleurisy. — The inflammation may be limited partly or
chiefly to the diaphragmatic surface. This is often a dry pleurisy, but there
may be effusion, either sero-fibrinous or purulent, which is circumscribed on
the diaphragmatic surface. In these cases the pain is low in the zone of the
diaphragm and may simulate that of acute abdominal disease. It may be
intensified by pressure at the point of insertion of the diaphragm at the tenth
rib. The diaphragm is fixed and the respiration is thoracic and short. Andral
noted in certain cases severe dyspnoea and attacks simulating angina. As
mentioned, the effusion is usually plastic, not serous. Serous or purulent effu-
sions of any size limited to the diaphragmatic surface are extremely rare.
Intense subjective with trifling objective features are always suggestive of dia-
phragmatic pleurisy.
Encysted Pleurisy. — The effusion may be circumscribed by adhesions or
separated into two or more pockets or loculi, which communicate with each
other. This is most common in empyema. In these cases there have usu-
ally been, at different parts of the pleura, multiple adhesions by which the
fluid is limited. In other instances the recent false membranes may encapsu-
late the exudation on the diaphragmatic surface, for example, or the part of
the pleura posterior to the mid-axillary line. The condition may be very puz-
zling during life, and present special difficulties in diagnosis. In some cases
the tactile fremitus is retained along certain lines of adhesion. The explora-
tory needle should be freely used.
Interlobar Pleurisy forms an interesting and not uncommon variety. In
nearly every instance of acute pleurisy the interlobar serous surfaces are also
involved and closely agglutinated together, and sometimes the fluid is encysted
between them. In this position tubercles are to be carefully looked for. In
a case of this kind following pneumonia there was between the lower and
upper and middle lobes of the right side an enormous purulent collection,
which looked at first like a large abscess of the lung. These collections may
perforate the bronchi^ and the cases present special difficulties in diagnosis.
Diagnosis of Pleurisy.
Acute plastic pleurisy is readily recognized. In the diagnosis of pleu-
ritic effusion the first question is. Does a fluid exudate exist ? the second. What
is its nature? In large effusions the increase in the size of the affected side,
the immobility, the absence of tactile fremitus, together with the displace-
652 DISEASES OF THE RESPIRATORY SYSTEM.
ment of organs, give infallible indications of the presence of fluid. The chief
difficulty arises in effusions of moderate extent, when the dulness, the pres-
ence of bronchophon}^, and, perhaps, tubular breathing may simulate pneu-
monia. The chief points to be borne in mind are : (a) Differences in the onset
and in the general characters of the two affections, more particularly the
initial chill, the higher fevei, more urgent dyspnoea, and the rusty expectora-
tion, which characterize pneumonia. As already mentioned, some of the cases
of pneumococcus pleurisy set in like pneumonia, (h) Certain physical signs
. — the more wooden character of the dulness, the greater resistance, and the
marked diminution or the absence of tactile fremitus in pleurisy. The aus-
cultatory signs may be deceptive. It is usually, indeed, the persistence of
tubular breathing, particularly the high-pitched, even amphoric expiration,
heard in some cases of pleurisy, which has raised the doubt. The intercostal
spaces are more commonly obliterated in pleuritic effusion than in pneumonia.
As already mentioned, the displacement of organs is a very valuable sign.
Nowadays with the hypodermic needle the question is easily settled. A sepa-
rate small syringe with a capacity of two drachms should be reserved for
exploratory purposes, and the needle should be longer and firmer than in the
ordinary hypodermic instrument. With careful preliminary disinfection the
instrument can be used with impunity, and in cases of doubt the exploratory
puncture should be made without hesitation. Pneumothorax is an occasional
sequence. The hypodermic needle is especially useful in those eases in which
there are pseudo-cavernous signs at the base. In cases, too, of massive pneu-
monia, in which the bronchi are plugged with fibrin, if the patient has not
been seen from the outset, the diagnosis may be impossible without it.
On the left side it may be difficult to differentiate a very large .pericardial
from a pleural effusion. The retention of resonance at the base, the presence
of Skoda's resonance toward the axilla, the absence of dislocation of the heart-
beat to the right of the sternum, the feebleness of the pulse and of the heart-
sounds, and the urgency of the dyspnoea, out of all proportion to the extent
of the effusion, are the chief points to be considered. Unilateral hydrothorax,
which is not at all uncommon in heart-disease, presents signs identical with
those of sero-fibrinous effusion. Certain tumors -within the chest may simu-
late pleural effusion. It should be remembered that many intrathoracic
growths are accompanied by exudation. Malignant disease of the lung and
of the pleura and hydatids of the pleura produce extensive dulness, with sup-
pression of the breath-sounds, simulating closely effusion.
On the right side, abscess of the liver and Iwdatid cysts may rise high into
the pleura and produce dulness and enfeebled breathing. Often in these cases
there is a friction sound, which should excite suspicion, and the upper outline
of the dulness is sometimes plainly convex. In a case of cancer of the kidney
the growth involved the diaphragm very early, and for months there were signs
of pleurisy before our attention was directed to the kidney. In all these
instances the exploratory puncture should be made.
The second question, as to the nature of the fluid, is quickly decided by
the use of the needle. The persistent fever, the occurrence of sweats, a leuco-
cytosis, and the increase in the pallor suggest the presence of pus. In chil-
dren the complexion is often sallow and earthy. In protracted cases, even in
children, when the general symptoms and the appearance of the patient have
. DISEASES OF THE PLEURA. 653
been most strongly suggestive of pus, the syringe has withdrawn clear fluid.
On the other hand, effusions of short duration may be purulent, even when
the general symptoms do not suggest it. The following statement may be
made with reference to the prognostic import of the bacteriological examina-
tion of the aspirated fluid : The presence of the pneumococcus is of favorable
significance, as such cases usually get well rapidly, even with a single aspira-
tion. The streptococcus empyema is the most serious form, and even after a
free drainage the patient may succumb to a general septicaemia. A sterile fluid
indicates in a majority of instances a tuberculous origin.
Treatment.
At the onset the severe pain may demand leeches, which usually give relief,
but a hypodermic of morphia is more effective. The Paquelin cautery may be
lightly but freely applied. It is well to administer a mercurial or saline purge.
Fixing the side by careful strapping with long strips of adhesive plaster, which
should pass well over the middle line, drawn tightly and evenly, gives great
relief, and I can corroborate the statement of F. T. Eoberts as to its efficacy.
Cupping, wet or dry, is now seldom employed. Blisters are of no special service
in the acute stages, although they relieve the pain. The ice-bag may be used
as in pneumonia. The open-air treatment should be begun early, as a majority
of the cases are tuberculous. Medicines are rarely required. A Dover's pow-
der may be given at night. Mercurials are not indicated.
When the effusion has taken place, mustard plasters or iodine, producing
slight counter-irritation, appear useful, particularly in the later stages. Iodide
of potassium is of doubtful benefit. By some the salicylates are believed to be
of special efficacy; but the drug treatment of the disease is most unsatisfac-
tory. The dry diet and frequent saline purges (given in concentrated form
before breakfast in Hay's method) may be tried. Recently it has been advised
to use a salt-free diet.
Early and if necessary repeated aspiration of the fluid is the most satis-
factory method of treatment. The results obtained by Delafield in 300 cases
treated by early aspiration (Am. Jour, of the Medical Sciences, 1900) have
never been equalled by any other method. The credit of introducing aspira-
tion in pleuritic effusions is due to Morrill Wyman, of Cambridge, Mass., and
Henry I. Bowditch, of Boston. Years prior to Dieulaf oy's work, aspiration was
in constant use at the Massachusetts General Hospital and was advocated
repeatedly by Bowditch. As the question is one of some historical interest, I
give Bowditch's conclusions concerning aspiration, expressed more than fifty-
five years ago, and which practically represent the opinion of to-day: " (1)
The operation is perfectly simple, but slightly painful, and can be done with
ease upon any patient in however advanced a stage of the disease. (3) It
should be performed forthwith in all cases in which there is complete filling
up of one side of the chest. (3) He had determined to use it in any case of
even moderate effusion lasting more than a few weeks and in which there
should seem to be a disposition to resist ordinary modes of treatment. (4)
He urged this practice upon the profession as a very important measure in
practical medicine; believing that by this method death may frequently be
prevented from ensuing either by sudden attack of dyspnoea or subsequent
phthisis, and, finally, from the gradual wearing out of the powers of life or
654 DISEASES OF THE RESPIRATORY SYSTEM.
inability to absorb the fluid.'' When the fluid reaches to tlie clavicle the indi-
cation for aspiration is imperative. Fever is not a contra-indication ; indeed,
sometimes with serous exudates the temperature falls after aspiration.
The operation is extremely simple and is practically. without risk. The spot
selected for puncture should be either in the seventh intercostal space in
the mid-axilla or at the outer angle of the scapula in the eighth space. The
arm of the patient should be brought forward with the hand on the opposite
shoulder, so as to widen the spaces. The needle should be thrust in close to
the upper margin of the rib, so as to avoid the intercostal artery, the wound-
ing of which, however, is an exceedingly rare accident. The fluid should be
withdrawn slowly. The amount will depend on the size of the exudate. If the
fluid reaches to the clavicle a litre or more may be withdrawn with safety. In
chronic cases of serous pleurisy after the failure of rejoeated tappings S. West
has shown the great value of free incision and drainage. He has reported
cases of recovery after effusions of fifteen and eighteen months' standing.
Symptoms and Accidexts during Paracentesis. — Pain is usually com-
plained of after a certain amount of fluid has been withdrawn ; it is sharp and
cutting in character. Coughing occurs toward the close, and may be severe
and paroxysmal. Pneumothorax may follow an exploratory puncture with a
hypodermic needle; it is rare during aspiration. Subcutaneous emphysema
may develop from the point of puncture, without the production of pneumo-
thorax. Ceredral symptoms. — Paintness is not uncommon. Epileptic con-
Milsions may occur either during the withdrawal or while irrigating the pleura.
These s3Tnptoms are very difficult to explain and are regarded by most authors
as of reflex origin. Hemiplegia may follow. And lastl}' sudden death may
occur either from sjmcope or during the convulsions.
As A. E. Eussell has pointed out, these serious and even fatal events may
follow exploratory puncture of the lung. Such accidents of paracentesis and
of washing out the pleura are explained by the studies of Capp and Lewis, who
have shown that a sudden and sometimes fatal fall in blood-pressure may fol-
low the experimental irrigation of the pleura in dogs. Expectoration of a
large quantity of alhuminous fuid may occur suddenly after the tapping, asso-
ciated with dyspnoBa. Some cases have proved rapidly fatal, with the features
of an acute oedema of the lungs. It has occurred only once in my practice.
Empyema is really a surgical affection, and I shall make only a few gen-
eral remarks upon its treatment. When it has been determined by explora-
tory puncture that the fluid is purulent, aspiration should not be performed,
except as preliminary to operation or as a temporary measure. Perhaps it is
better not to have an exception to this rule, although the empyemas of children
and the pneumonic empyema occasionally get well rapidly after a single tap-
ping. It is sad to think of the number of lives which are sacrificed annually
by the failure to recognize that empyema should be treated as an ordinary
abscess, by free incision. The operation dates from the time of Hippocrates
and is b}^ no means serious. A majority of the cases get well, provided that
free drainage is obtained, and it makes no difference practically what measures
are followed so long as this indication is met. The good results in any method
depend upon the thoroughness with which the cavity is drained. Irrigation of
tlie cavity is rarely necessary unless the contents are fetid. In the subsequent
treatment a point of great importance in facilitating the closure of the cavity
DISEASES OF THE PLEURA. 655
is the distention of the lung on the affected side. This may be acconiplislied
by the method advised by Kalston James, whicli has been practised with great
success in the surgical wards of the Johns Hopkins Hospital. The patient
daily, for a certain length of time, increasing gradually with the increase of
his strength, transfers by air-pressure water from one bottle to another. The
bottles should be large, holding at least a gallon each, and by the arrangement
of tubes, as in the WolfE's bottle, an expiratory effort of the patient forces the
water from one bottle into the other. Equally efficacious is the plan advised by
Naunyn. The patient sits in an arm chair grasping strongly one of the rungs
with the hand and forcibly compressing the sound side against the arm of the
chair ; then forcible inspiratory efforts are made which act chiefly on the com-
pressed lung, as the sound side is fixed. The abscess cavity is gradually closed,
partly by the falling in of the chest wall and partly by the expansion of the
lung. In some instances it is necessary to resect portions of one or more ribs.
The physician is often asked, in cases of empyema with emaciation, hectic
and feeble rapid pulse, whether the patient could stand the operation. Even
in the most desperate cases the surgeon should never hesitate to make a free
incision.
II. CHRONIC PLEURISY.
This affection occurs in two forms :
( 1 ) Chronic pleurisy with effusion, in which the disease may set in insidi-
ously or may follow an acute sero-fibrinous pleurisy. There are cases in which
the liquid persists for months or even years without undergoing any special
alteration and without becoming purulent. Such cases have the characters
which we have described under pleurisy with effusion.
(2) Chronic dry pleurisy. — The cases are met with (a) as a sequence of
ordinary pleural effusion. When the exudate is absorbed and the layers of the
pleura come together there is left between them a variable amount of fibrinous
material which gradually undergoes organization, and is converted into a layer
of firm connective tissue. This process goes on at the base, and is represented
clinically by a slight grade of flattening, deficient expansion, defective reso-
nance on percussion, and enfeebled breathing. After recovery from empyema
the flattening and retraction may be still more marked. In both cases it is a
condition which can be greatly benefited by pulmonary gymnastics. In these
firm, fibrous membranes calcification may occur, particularly after empyema.
It is not very uncommon to find between the false membranes a small pocket
of fluid forming a sort of pleural cyst. In the great majority of these cases
the condition is one which need not cause anxiety. There may be an occa-
sional dragging pain at the base of the lung or a stitch in the side, but patients
may remain in perfectly good health for years. The most advanced grade of
this secondary dry pleurisy is seen in those cases of empyema which have been
left to themselves and have perforated and ultimately healed by a gradual
absorption or discharge of the pus, with retraction of the side of the chest and
permanent carnification of the lung. Traumatic lesions, such as gunshot
wounds, may be followed by an identical condition. Post mortem, it is quite
impossible to separate the layers of the pleura, which are greatly thickened,-
particularly at the base, and surround a compressed, airless, fibroid lung.
Bronchiectasis may gradually ensue, and in one remarkable case which I saw
656 DISEASES OF THE RESPIRATORY SYSTEM.
on several occasions with Blackader, of Montreal, not only on the affected side,
but also in the lower lobe of the other lung.
(h) Primitive dry pleurisy. This condition may directly follow the acute
23lastic pleurisy alread}' described; but it may set in without any acute symp-
toms whatever, and the patient's attention may be called to it by feeling the
pleural friction. A constant effect of this primitive dry pleurisy is the adhe-
sion of the layers. This is probably an invariable result, whether the pleurisy
is primary or secondary. The organization of the thin layer of exudation in
a pneumonia will unite the two surfaces by delicate bands. Pleural adhesions
are extremel}^ common, and it is rare to examine a hodj entirely free from
them. They may be limited in extent or universal. Thin fibrous adhesions do
not produce any alteration in the percussion characters, and, if limited, there
is no special change heard on auscultation. When, however, there is general
s}Tiechia on both sides the expansile movement of the lung is considerably im-
paired. AYe should naturally think that universal adhesions would interfere
materiall}' vrith the function of the Kmgs, but practically we see many instances
in which there has not been the slightest disturbance. The physical signs of
total adhesion are by no means constant. It has been stated that there is a
marked disproportion between the degree of expansion of the chest walls and
the intensity of the vesicular murmur, but the latter is a very variable factor,
and under perfecth' normal conditions the breath-sounds, with verv full chest
expansion, may be extremely feeble. The diaphragm phenomenon — Litten's
sign — is absent.
As already stated, it is possible, as the late Sir Andrew Clark held, that
a primitive dry pleurisy may gradually lead to great thickening of the mem-
branes, and ultimate invasion of the limg, causing a cirrhosis.
Lastly, there is a primitive dry pleurisy of tuljerculous origin. In it both
parietal and costal layers are greatly thickened — perhaps from 2 to 3 mm. each
— and present firm fibroid, caseous masses and small tubercles, while uniting
these two greatly thickened layers is a reddish-gray fibroid tissue, sometimes
infiltrated with serum. This may be a local process confined to one pleura,
or it may be in both. These cases are sometimes associated with a similar con-
dition in the pericardium and peritonseum.
Occasionally remarkable vaso-motor phenomena occur in chronic pleurisy,
whether simple or in connection with tuberculosis of an apex. Flushing or
sweating of one cheek or dilatation of the pupil are the common manifesta-
tions. They appear to be due to involvement of the first thoracic ganglion at
the top of the pleural cavity.
III. HYDROTHORAX.
Hydrothorax is a transudation of simple non-inflammatory fluid into the
pleural cavities, and occurs as a secondary process in many affections. The
fluid is clear, without any flocculi of fibrin, and the membranes are smooth.
It is met with more particularly in connection with general dropsy, either
reDiil^aj;dJ^(^jor_Ji^mic. It may, however, occur alone, or with only slight
cedema of the feet. A child was admitted to the ^lontreal General Hospital
with urgent dyspncea and cyanosis, and died the night after admission. She
had extensive bilateral hydrothorax, which had come on early in the nephritis
DISEASES OF THE PLEURA. 657
of scarlet fever. In renal disease hjclrotliQia-^i^s almost always bilateral, but
in heart affections one pleura is more commonly involved! The physical signs
are those of pleural effusion, but the exudation is rarely excessive. In kidney
and heart-disease, even when there is no general dropsy, the occurrence of
dyspnoea should at once direct attention to the pleura, since many patients are
carried off by a rapid effusion. In chronic valvular disease the effusion is usu-
ally on the right side, and may recur for months. Stengel attributes' the
greater frequency of the dextral effusion to compression of the azygos veins.
Post-mortem records show the frequency with which this condition is over-
looked. The saline purges will in many cases rapidly reduce the effusion, but,
if necessary, aspiration should repeatedly be practised.
IV. PNEUMOTHORAX.
(Hydro-Pneumothorax and Pyo-Pneumothorax.)
Air alone in the pleural cavity, to which the term pneumothorax is strictly
applicable, is an extremely rare condition. It is almost invariably associated
with a serous fluid — hydro-pneumothorax, or with pus — pyo-pneumothorax.
Etiology. — There exists normally within the pleural cavity of an adult
a negative pressure of several (3 to 5 ) millimetres of mercury, due to the recoil
of the distended, perfectly elastic lung. Hence through any opening connect-
ing the pleural cavity with the external air we should expect air to rush in
until this negative pressure is relieved. To explain the absence of pneumo-
thorax in a few cases of external injury laying the pleura bare, in which it
would be expected, S. West has assumed the ^existence of a cohesion between
the pleurae, but this force has not as yet been satisfactorily demonstrated.
In a case of pneumothorax, if the opening causing it remain patent, which
occurs only in some external wounds, or especially perforations through con-
solidated areas of the lungs, the intrathoracic pressure will be that of the
atmosphere, the lung will be found to have collapsed as much as possible by
virtue of its own elastic tension, the intercostal grooves obliterated, the heart
displaced to the other side, and the diaphragm lower than normal, because the
negative pressure by reason of which these organs are partly retained in their
ordinary position has been relieved. If the opening becomes closed the intra-
thoracic pressure may rise above the atmospheric and the above-mentioned
displacements be much increased. But most perforations through the lung
are valvular, a property of lung tissue, and the intrapleuratl^ressure is soon
about 7 mm. 'of mercury. If there be a fluid exudate the pressure may be
, higher, but the high pressures supposed are more apparent than real, and that
measured at the autopsy table is quite surely not that during life. It is more
a question of the amount of distention than the actual pressure which deter-
mines the discomfort of the patient.
Pneumothorax arises : ( 1 ) In perforating wounds of the chest, in which
case it is sometimes associated with extensive cutaneous emphysema. It may
follow exploratory puncture either with a small needle or an aspirator. There
were ten cases in my series. Pneumothorax rarely follows fracture of the rib,
even though the lung may be torn. (2) In perforation of the pleura through
the diaphragm, usually by malignant disease of the stomach or colon, or abscess
43
658 DISEASES OF THE RESPIRATORY SYSTEM.
of the liver perforating lung and pleura. The pleura may also he perforated
in cases of cancer of the oesophagus. (3) When the lung is perforated. This
is by far the most common cause, and may occur: (a) In the normal lung
from rupture of the air- vesicles during straining or even when at rest. Special
attention has been called to this accident by S. West and De H. Hall. The
air may be absorbed and no ill effect follow. It does not necessarily excite
pleurisy, as pointed out many years ago by Gairdner, but inflammation and
effusion are the usual result. In a recent case the condition developed as the
patient was going down-stairs ; no effusion followed ; he did not react to tuber-
culin, (&) From perforation due to local disease of the lung, either the soften-
ing of a caseous focus or the breaking of a tuberculous cavity. According to
S. West, 90 per cent of all the cases are due to this cause. Less common
are the cases due to septic broncho-pneumonia and to gangrene. A rare cause
is the breaking of a hsemorrhagic infarct in chronic heart-disease, of which I
met an instance a few years ago. (c) Perforation of the lung from the pleura,
which arises in certain cases of empyema and produces a pleuro-bronchial
fistula. (4) Spontaneously, by the development in pleural exudates of the
gas bacillus {B. ah'ogenes capsulatiis Welch). Of 48 cases, the basis of
Emerson's exhaustive monograph (J. H. H. Eeports, vol, xi), 22 were tuber-
culous, 6 were the result of trauma, 10 of aspiration, 2 were spontaneous, 2
followed bronchiectasis, 2 abscess of the lung, 1 gangrene, 2 an empyema,
and 1 abscess of the liver perforating through the lung.
Pneumothorax occurs chiefly in adults, though cases are met with in very
young children. It is more frequent in males than in females.
A remarkable recurrent variety has been described by S. West, Goodhart,
and Furney. In Goodhart's case the pneumothorax developed first in one
side and then in the other.
Morbid Anatomy. — If the trocar or blow-pipe is inserted between the ribs,
there may be a jet of air of sufficient strength to blow out a lighted match.
On opening the thorax the mediastinum and pericardium are seen to be
pushed, or rather, as Douglas Powell pointed out, " drawn over " to the oppo-
site side ; but, as before mentioned, the heart is not rotated, and the relation of
its parts is maintained much as in the normal condition. A serous or puru-
lent fluid is usually present, and the membranes are inflamed. The cause of
the pneumothorax can usually be found without difficulty. In the great
majority of instances it is the perforation of a tuberculous cavity or a break-
ing of a superflcial caseous focus. The orifice of rupture may be extremely
small. In chronic cases there may be a fistula of considerable size communi-
cating with the bronchi. The lung is usually compressed and carnified.
Symptoms. — The onset is usually sudden and characterized by severe pain
in the side, urgent dyspnoea, and signs of general distress, as indicated by
slight lividity and a very rapid and feeble pulse — the pneumothorax accutis-
simus of TJnverricht. There may, however, be no urgent symptoms, particu-
larly in cases of long-standing phthisis.
Physical Signs. — The physical signs are very distinctive. Inspection
shows marked enlargement of the affected side with immobility. The heart
impulse is usually much displaced. On palpation the fremitus is greatly
diminished or more commonly abolished. On percussion the resonance may be
tympanitic or even have an amphoric quality. This, however, is not always
DISEASES OF THE PLEURA. 659
the case. It may be a flat tympany, resembling Skoda's resonance. In some
instances it may be a full, hyperresonant note, like emphysema; while in
others — and this is very deceptive — there is dulness. These extreme variations
depend doubtless upon the degree of intrapleural tension. On several occasions
I have known an error in diagnosis to result from ignorance of the fact that,
in certain instances, the percussion note may be " muffled, toneless, almost
dull" (Walshe), There is usually dulness at the base from effused' fluid,
which can readily be made to change the level by altering the position of the
patient. Movable dulness can be obtained much more readily in pneumothorax
than in a simple pleurisy. On auscultation the breath-sounds are suppressed.
Sometimes there is only a distant feeble inspiratory murmur of marked am-
phoric quality. The contrast between the loud exaggerated breath-sounds on
the normal side and the absence of the breath-sounds on the other is very
suggestive. The rales have a peculiar metallic quality, and on coughing or
deep inspiration there may be what Laennec termed the metallic tinkling.
The voice, too, has a curious metallic echo. What is sometimes called the
coin-sound, termed by Trousseau the bruit d'airain, is very characteristic.
To obtain it the auscultator should place one ear on the back of the chest
wall while the assistant taps one coin on another on the front of the chest.
The metallic echoing sound which is produced in this way is one of the most
constant and characteristic signs of pneumothorax. And, lastly, the Hip-
pocratic succussion splash may be obtained when the auscultator's head is
placed upon the chest while the patient's body is shaken. A splashing sound
is produced, which may be audible at a distance. A patient may himself
notice it in making abrupt changes in posture. The signs, distention, immo-
bility, lack of vocal fremitus, hyperresonance, absence of breath-sounds and
coin-sound, are those of the pure pneumothorax of Laennec. The metallic
phenomena may be present, e. g., the metallic tinkling and amphoric respira-
tion, but these are best heard in cases with a consolidated lung and thickened
pleura, such as occur in tuberculosis. The movable dulness and splash on
succussion depend on fluid. Of other physical signs displacement of organs
is most constant. As already mentioned, the heart may be much " drawn
over " to the opposite side, and the liver greatly displaced, so that its upper
surface is below the level of the costal margin, a degree of dislocation never
seen in simple effusion.
Diagnosis. — The diagnosis of pneumothorax rarely offers any difficulty, as
the signs are very characteristic. In cases in which the percussion note is dull
the condition may be mistaken for effusion. I made this mistake in a case of
pulsating pleurisy, in which the pneumothorax followed heavy lifting, and
it was not until several days later, after some of the fluid had been with-
drawn, that a tympanitic note developed. Diaphragmatic hernia following
a crush or other accident may closely simulate pneumothorax.
In cases of very large phthisical cavities with tympanitic percussion reso-
nance and rales of an amphoric, metallic quality, the question of pneumothorax
is sometimes raised. In those rare instances of total excavation of one lung
the amphoric and metallic phenomena may be most intense, but the absence of
dislocation of the organs, of the succussion splash, and of the coin-sound
suffice to differentiate this condition. While this is true in the great majority
of cases, I have heard the bruit d'airain over a large cavity in the right upper
660 DISEASES OF THE RESPIRATORY SYSTEM.
lobe. The condition of pyo-pneumothorax subphrenicus may simulate closely
true pnemnothorax.
Prognosis'. — The prognosis in cases of pneumothorax depends largely upon
the cause. S. West gives a mortality of 70 per cent.' The tuberculous cases
usually die within a few weeks. Of 39 cases, 29 died within a fortnight
(West) ; 10 patients died on the first day, 2 within twenty and thirty minutes
respectively of the attack. Of our 22 tuberculous cases 20 died, and 5 of the
10 cases following aspiration. Pneumothorax in a healthy individual often
ends in recovery. There are tuberculous cases in which the pneumothorax,
if occurring early, seems to arrest the progress of the tuberculosis. There
is a chronic pneumothorax which may last for between three and four years.
It may be a chronic condition, as in the case just mentioned, and a fair
measure of health may be enjoyed.
Treatment. — There are three groups of cases: First, in the pneumothorax
accutissimus, with urgent dyspnoea, great displacement of the heart, cyanosis,
and low blood pressure, an opening should be made in the pleura and kept
open, converting a valvular into an open variety. Immediate aspiration with a
trocar has saved life. Second!}^, the spontaneous cases which usually do well,
as the air is quickly absorbed ; so also with the traumatic variety. Very many
of the tuberculous cases are best let alone, if the patient is doing well, or if
the disease in the other lung is advanced. Thirdly, when there is pus, and
the patient is not doing well, or in the tuberculous variety if the other lung
is not involved, pleurotomy, or resection of one or two ribs, may be done. Of
nine cases in my series two recovered.
V. AFFECTIONS OF THE MEDIASTINUM.
(1) Simple Lymphadenitis. — In all inflammatory affections of the bronchi
and of the lungs the groups of lymph-glands in the mediastinum become swol-
len. In the bronchitis of measles, for example, and in simple broncho-pneu-
monia the bronchial glands are large and infiltrated, the tissue is engorged and
oedematous, sometimes intensely hypergemic. Much stress has been laid by
some writers on this enlargement of the glands in the posterior mediastinum,
and De Mussy held that it was an important factor in inducing paroxysms of
whooping-cough. They may attain a size sufficient to induce dulness beneath
the manubrium and in the upper part of the interscapular regions behind,
though this is often difficult to determine. In reality the glands lie chiefly
upon the spine, and unless those which are deep in the root of the lung are
large enough to induce compression of the adjacent lung tissue, I doubt if the
ordinary bronchial adenopathy ever can be determined by percussion in the
upper interscapular region. I have never met with an instance in which the
compression of either bronchus seemed to have resulted from the glands, how-
ever large. Tuberculous affection of these glands has already been considered.
(2) Suppurative Lymphadenitis. — Occasionally abscess in the bronchial or
tracheal lymph-glands is found. It may follow the simple adenitis, but is
most frequentl}'' associated with the presence of tubercle. The liquid portion
may gradually become absorbed and the inspissated contents undergo calcifica-
tion. Serious accidents occasionally occur, as perforation into the oesophagus
or into a bronchus, or in rare instances, as in the case reported by Sidney
DISEASES OF THE PLEURA. 661
Phillips, perforation of the aorta, as well as a bronchus, which, it is remarkable
to say, did not prove fatal rapidly, but caused repeated attacks of haemoptysis
during a period of sixteen months.
(3) Tumors; Cancer and Sarcoma. — In Hare's elaborate study of 520 cases
of disease of the mediastinum there were 134 cases of cancer, 98 cases of sar-
coma, 21 cases of lymphoma, 7 cases of fibroma, 11 cases of dermoid cysts, 8
cases of hydatid cysts, and instances of lipoma, gumma, and enchondroma.
From this we see that cancer is the most common form of growth. The tumor
occurred in the anterior mediastinum alone in 48 of the cases of cancer and in
33 of the cases of sarcoma. There are three chief points of origin, the thymus,
the lymph-glands, and the pleura and lung. Sarcoma is more frequently
primary than cancer. Males are more frequently affected than females. The
age of onset is most commonly between thirty and forty.
Symptoms. — The signs of mediastinal tumor are those of intrathoracic
pressure. In some cases almost the entire chest is filled with the masses.
The heart and lungs are pushed back and it is marvelous how life can be
maintained with such dislocation and compression of the organs. Dyspncea
is one of the earliest and most constant symptoms, and may be due either to
pressure on the trachea or on the recurrent laryngeal nerves. It may indeed
be cardiac, due to pressure upon the heart or its vessels. In a few cases it
results from the pleural effusion which so frequently accompanies intrathoracic
growths. Associated with the dyspncea is a cough, often severe and parox-
ysmal in character, with the brazen quality of the so-called aneurismal cough
when a recurrent nerve is involved. The voice may also be affected from a
similar cause. Pressure on the vessels is common. The superior vena cava
may be compressed and obliterated, and when the process goes on slowly
the collateral circulation may be completely established. Less commonly the
inferior vena cava or one or other of the subclavian veins is compressed. The
arteries are much more rarely obstructed. There may be dysphagia, due to
compression of the oesophagus. In rare instances there are pupillary changes,
either dilatation or contraction, due to involvement of the sympathetic. Ex-
pectoration of blood, pus, and hair is characteristic of the dermoid cyst, of
which Christian has collected 40 cases.
Physical Signs. — On inspection there may be orthopnoea and marked
cyanosis of the upper part of the body. In such instances, if of long dura-
tion, there are signs of collateral circulation and the superficial mammary
and epigastric veins are enlarged. In these cases of chronic obstruction the
finger-tips may be clubbed. There may be bulging of the sternum or the
tumor may erode the bone and form a prominent subcutaneous growth. The
rapidly growing lymphoid tumors more commonly than others perforate the
chest wall. In 4 of 13 cases of Hodgkin's disease, there was mediastinal
growth, and in 3 instances the sternum was eroded and perforated. The per-
foration may be on one side of the breast-bone. The projecting tumor may
pulsate ; the heart may be dislocated and its impulse much out of place. Con-
traction of one side of the thorax has been noted in a few instances. On pal-
pation the fremitus is absent wherever the -tumor reaches the chest wall. If
pulsating, it rarely has the forcible, heaving impulse of an aneurismal sac. On
auscultation there is usually silence over the dull region. The heart-sounds
are not transmitted and the respiratory murmur is feeble or inaudible, rarely.
662 DISEASES OF THE RESPIRATORY SYSTEM.
bronchial. Vocal resonance is, as a rule, absent. Signs of pleural effusion
occur in a great many instances of mediastinal growth, and in doubtful cases
the aspirator needle should be used.
Tumors of the anterior mediastinum originate usually in the thymus, or
its remnants, or in the connective tissue; the sternum is pushed forward and
often eroded. The growth may be felt in the suprasternal fossa; the cervical
glands are usually involved. The pressure symptoms are chiefly upon the
venous trunks. Dyspnoea is a prominent feature.
Intrathoracic tumors in the middle and posterior mediastinum originate
most commonly in the Ijnnpli-glands. The sjmiptoms are out of all propor-
tion to the physical signs; there is urgent dyspnoea and cough, which is some-
times loud and ringing. The pressure symptoms are chiefly upon the gullet,
the recurrent lar}Tigeal, and sometimes upon the az3^gos vein.
In a third group, tumors originating in the pleura and the lung, the
pressure s}Tnptoms are not so marked. Pleural exudate is very much more
common ; the patient becomes anaemic and emaciation is rapid. There may be
secondary involvement of the lymph-glands in the neck.
DiAGXosis. — The diagnosis of mediastinal tumor from aneurism is some-
times extremely difficult. An interesting case reported and figured by Soko-
losski, in Bd. 19 of the Deutsclies Archiv fiir klinische Medicin, "in which
Oppolzer diagnosed aneurism and Skoda mediastinal tumor, illustrates how in
some instances the most skilful of observers may be unable to agree. Scarcely
a sign is found in aneurism which may not be duplicated in mediastinal
tumor. This is not strange, since the symptoms in both are largely due to
pressure. The cyanosis, the venous engorgement, the signs of collateral cir-
culation are as a rule much more marked in tumor. The time element is
important. If a case has persisted for more than eighteen months the dis-
ease is probably aneurism. There are, however, exceptions to this. By far
the most valuable sign of aneurism is the diastolic shock so often to be felt,
and in a majority of cases to be heard, over the sac. This is rarely, if ever,
present in mediastinal growths, even when they perforate the sternum and
have communicated pulsation. Tracheal tugging is rarely present in tumor.
Another point of importance is that a tumor, advancing from the medias-
tinum, eroding the sternum and appearing externally, if aneurismal, has
forcible, heaving, and distinctly expansile pulsations. The radiating pain in
the back and axms and neck is rather in favor of aneurism, as is also a bene-
ficial influence on it of iodide of potassium. The remarkable traumatic cya-
nosis of the upper half of the body which follows compression injuries of the
thorax could scarcely be mistaken for the effect of tumor.
The frequency of pleural effusion in connection with mediastinal tumor
is to be constantly borne in mind. It may give curiously complex characters
to the physical signs — characters which are profoundly modified after aspira-
tion of the liquid. Occasionally a tumor of the mediastinum is operable.
Walker, of Detroit, showed me a large fibro-sarcoma, which he had removed
successfully from the anterior mediastinum.
(4) Abscess of the Mediastinum. — Hare collected 115 cases of mediastinal
abscess, in 77 of which there were details sufficient to permit the analysis.
Of these cases the great majority occurred in males. Forty-four were instances
of acute abscess. The anterior mediastinum is most commonly the seat of the
DISEASES OF THE PLEURA. 663
suppuration. The cases are most frequently associated with trauma. Some
have followed erysipelas or occurred in association with eruptive fevers.
Many caseSj particularly the chronic abscesses, are of tuberculous origin. Of
symptoms, pain behind the sternum is the most common. It may be of a
throbbing character, and in the acute cases is associated with fever, sometimes
with chills and sweats. If the abscess is large there may be dyspnoea. The
pus may burrow into the abdomen, perforate through an intercostal space, or it
may erode the sternum. Instances are on record in which the abscess has
discharged into the trachea or oesophagus. In many cases, particularly of
chronic abscess, the pus becomes inspissated and produces no ill effect. The
physical signs may be very indefinite. A pulsating and fluctuating tumor
may appear at the border of the sternum or at the sternal notch. The absence
of bruit, of the diastolic shock, and of the expansile pulsation usually enables
a correct diagnosis to be made. When in doubt a fine hypodermic needle may
be inserted.
(5) Indurative Mediastino-Pericarditis. — Harris has reviewed the subject.
In one form there is adherent pericardium and great increase in the fibrous
tissues of the mediastinum; in another there is adherent pericardium with
union to surrounding parts, but very little mediastinitis ; in a third the peri-
cardium may be uninvolved. The disease is rare ; of 22 cases 17 were in males ;
only 2 were above thirty years of age. The symptoms are essentially those of
that form of adhesive pericardium which is associated with great hypertrophy
and dilatation of the heart, and in which the patients present a picture of cya-
nosis, dyspnoea, anasarca, etc. The pulsus paradoxus, described by Kussmaul,
is not distinctive. Occasionally there is also a proliferative peritonitis. Medi-
astinal friction is sometimes heard in patients with adhesive mediastino-peri-
carditis — dry, coarse, crackling rales heard along the sternum, particularly
when the arms are raised.
(6) Miscellaneous Affections. — In Hare's monograph there were 7 in-
stances of fibroma, 11 cases of dermoid cyst, 8 cases of hydatid cyst, and
cases of lipoma and gumma.
(7) Emphysema of the Mediastinum. — Air in the cellular tissues of the
mediastinum is met with in cases of trauma, and occasionally in fatal cases
of diphtheria and in whooping-cough. It may extend to the subcutaneous
tissues, Champneys has called attention to its frequency after tracheotomy,
in which, he says, the conditions favoring the production are division of the
deep fascia, obstruction in the air-passages, and inspiratory efforts. The deep
fascia, he says, should not be raised from the trachea. It is often associated
with pneumothorax, and more often in rupture of the lung without pneumo-
thorax, the pleura remaining intact and the air dissecting its way along the
bronchi into the mediastinum and into the neck. The condition seems by no
means uncommon. Angel Money found it in 16 of 28 cases of tracheotomy,
and in 2 of these pneumothorax also was present.
SECTION VII.
DISEASES OF THE KIDISTETS.
I. MALFORMATIONS.
Newman classifies the malformations of the kidney as follows : A. Displace-
ments without mobility — (1) congenital displacement without deformity;
(2) congenital displacement with deformity; (3) acquired displacements.
B. Malformations of the kidney. I. Variations in number — (a) supernumer-
ary kidney; (&) single kidney^ congenital absence of one kidney, atrophy of
one kidney; (c) absence of both kidneys. II. Variations in form and size
— (a) general variations in form, lobulation, etc.; (&) hypertrophy of one
kidney; (c) fusion of two kidneys — ^horseshoe kidney, sigmoid kidney, disk-
shaped kidney. C. Variations in pelvis, ureters, and blood-vessels.
The fused kidneys may form a large mass, which is often displaced, being
either in an iliac fossa or in the middle line of the abdomen, or even in the
pelvis. Under these circumstances it may be mistaken for a new growth. In
Polk's case the organ was removed under the belief that it was a floating kid-
ney. The patient lived eleven days, had complete anuria, and it was found
post mortem that a single fused kidney had been removed. A second case of
the same kind has been reported.
II. MOVABLE KIDNEY.
(Floating- Kidney; Palpable Kidney; Ren mobilis; Nephroptosis.)
The kidney is held in position by its fatty capsule, by the peritongeum
which passes in front of it, and by the blood-vessels. Normally the kidney
is firmly fixed, but under certain circumstances one or the other organ, more
rarely both, becomes movable. In very rare cases the kidney is surrounded,
to a greater or less extent, by the peritonaeum, and is anchored at the hilus
by a mesonephron. Some would limit the term floating kidney to this con-
dition.
Movable kidney is almost always acquired. It is more common in women.
Of the 667 cases collected in the literature by Kuttner, 584 were in women
and only 83 in men. It is more common on the right than on the left side.
Of 727 cases analyzed by this author, it occurred on the right in 553 cases, on
the left in 81, and on both sides in 93. The greater frequency of the con-
dition in women may be attributed to compression of the lower thoracic zone
by tight lacing, and, more important still, to the relaxation of the abdominal
walls which follows repeated pregnancies. This does not account for all the
664
MOVABLE KIDNEY. 665
eases, as movable kidney is by no means uncommon in nulliparae. Drummond
believes that in a majority of the cases there is a congenitally relaxed condition
of the peritoneal attachments. The condition has been met with in infants and
in children. Wasting of the fat about the kidney may be a cause in some in-
stances. Trauma and the lifting of heavy weights are occasionally factors in
its production. The kidney is sometimes dragged down by tumors. The
greater frequency on the right side is probably associated with the position of
the kidney just beneath the liver, and the depression to which the organ is
subjected with each descent of the diaphragm in inspiration.
And, lastly, movable kidney is met with in many cases which present that
combination of neurasthenia with gastro-intestinal disturbance which has been
described by Glenard as enteroptosis (see p. 528).
To determine the presence of a movable kidney the patient should be
placed in the dorsal position, with the head moderately low and the abdominal
walls relaxed. The left hand is placed in the lumbar region behind the
eleventh and twelfth ribs; the right hand in the hypochondriac region, in
the nipple line, just under the edge of the liver. Bimanual palpation may
detect the presence of a firm, rounded body just below the edge of the ribs.
If nothing can be felt, the patient should be asked to draw a deep breath, when,
if the organ is palpable, it is touched by the fingers of the right hand. Vari-
ous grades of mobility may be recognized. It may be possible barely to feel
the lower edge on deep palpation — palpable Tcidney — or the organ may be so
far displaced that on drawing the deepest breath the fingers of the right hand
may be, in a thin person, slipped above the upper end of the organ, which can
be readily held down, but can not be pushed below the level of the navel —
rn'ovahle Tcidney. In a third group of cases the organ is freely movable, and
may even be felt just above Poupart's ligament, or may be in the middle line
of the abdomen, or can even be pushed over beyond this point. To this the
term floating kidney is appropriate.
The movable kidney is not painful on pressure, except when it is grasped
very firmly, when there is a dull pain, or sometimes a sickening sensation.
Examination of the patient from behind may show a distinct flattening in the
lumbar region on the side in which the kidney is mobile.
Symptoms. — In a large majority of cases there are no symptoms, and if
detected accidentally it is well not to let the patient know of its presence. Far
too much stress has been laid upon the condition of late years. In other in-
stances there is pain in the lumbar region or a sense of dragging and discom-
fort, or there may be intercostal neuralgia. In a large group the symptoms
are those of neurasthenia with dyspeptic disturbance. In women the hysterical
symptoms may be marked, and in men various grades of hypochondriasis.
The gastric disturbance is usually a form of nervous dyspepsia. Dilatation
of the stomach has been observed, owing, as suggested by Bartels, to pressure of
the dislocated kidney upon the duodenum. This view has been supported by
Oser, Landau, and Ewald. On the other hand, Litten holds that the dilata-
tion of the stomach is the cause of the mobility of the kidney, and he found
in 40 cases of depression and dilatation of the stomach 22 instances of dislo-
cation of the kidney on the right side. The association, however, with a
depressed stomach is certainly common in women. Constipation is not infre-
quent. Some writers have described pressure upon the gall-duets, with jaun-
44
666 DISEASES OF THE KIDNEYS.
dice, but tliis is ver}" rare. Fffical accumulation and even obstruction may be
associated ■vritli the displaced organ.
Dletl's Ceises. — In floating kidney tbere are attacks characterized by
severe abdominal pain^ chills, nausea, vomiting, fever, and collapse. The
symptoms vrere first described by Diet! in 1864, and a more wide-spread knowl-
edge of their occurrence in connection with this condition is desirable. My
attention was called to them in 1880 by Palmer Howard in the case of a stout
lady, who suifered repeatedly with the most severe attacks of abdominal pain
and vomiting, which constantly required morphia. A tumor was discovered
a little to the right of the navel, and the diagnosis of probable neoplasm was
concurred in by Flint (Sr.) and Gaillard Thomas. The patient lost weight
rapidly, became emaciated, and in the spring of 1881 again went to oSTew
York, where she saw Van Buren, who diagnosed a floating kidney and said
that these paroxysms were associated with it in a gouty person. He cut off all
stimulants, reassured the lady that she had no cancer, and from that time she
rapidly recovered, and the attacks have been few and far between. In this
patient any overindulgence in eating or in drinking is stdl liable to be fol-
lowed by a very severe attack. These attacks may also be mistaken for renal
colic, and the operation of nephrotomy has been performed.
In other instances the attacks of pain may be thought to be due to in-
testinal disease or to recurring appendicitis. The cause of these paroxj^smal
attacks is not quite clear. Dietl thought the}^ were due to strangulation of the
kidney or to twists or kinks in the renal vessels due to the extreme mobility.
During the attacks the urine is sometimes high-colored and contains an excess
of uric acid or of the oxalates. It is stated, too, that blood or pus may be
present. The kidney may be tender, swollen, and less freely movable. Che3Tie
describes intermittent hsematuria in tliis condition.
Intermittent l\y drone plirosis is sometimes associated with movable kidney.
Three cases are reported in my Lectures on Abdominal Tumors. In two the
condition has been completely relieved by a well-adapted pad and belt ; in the
third, attacks recur at long intervals.
The diagnosis is rarely doubtful, as the shape of the organ is usually
distinctive and the mobility marked. Tumors of the gall-bladder, ovarian
growths, and tumors of the bowels may in rare instances be confounded with it.
Treatment. — The kidney has been extirpated in many instances, but the
operation is not without risk, and there have been several fatal cases. Stitch-
ing of the kidne}* — ^nephrorrhaphy — as recommended by Hahn, is the most
suitable procedure, and relief is afforded in many cases by the operation,
though not in all. Treatment designed to increase fat-formation often helps
to hold the kidney in place. In the neurasthenic cases a prolonged rest treat-
ment is indicated.
In many instances the greatest relief is experienced from a bandage and
pad. It should be applied in the morning, vrith the patient in the dorsal or
knee-breast position, and she should be taught how to push up the kidney. An
air pad may be used if the organ is sensitive. In other cases a broad bandage
well padded in the lower abdominal zone pushes up the intestines and makes
them act as a support. In the attacks of severe colic morphia is required.
When dependent, as seems sometimes the case, upon an excess of uric acid or
the oxalates, the diet must be carefullv regulated.
CIRCULATORY DISTURBANCES. mi
III. CIRCULATORY DISTURBANCES.
Normally the secretion of urine is accomplished by the maintenance of
a certain blood-pressure within the glomeruli and by the activity of the renal
epithelium. Bowman's views on this question have been generally accepted,
and the watery elements are held to be filtered from the glomeruli ; the amount
depending on the rapidity and the pressure of the blood-current ; the quality,
whether normal or abnormal, depending upon the condition of the capillary
and glomerular epithelium; while the greater portion of the solid ingredients
are excreted by the epithelium of the convoluted tubules. The integrity of the
epithelium covering the capillary tufts within Bowman's capsule is essential to
the production of a normal urine. If under any circumstances their nutrition
fails, as when, for example, the rapidity of the blood-current is lowered, so that
they are deprived of the necessary amount of oxygen, the material which filters
through is no longer normal (i. e., water), but contains serum albumin. Colm-
heim has shown that the renal epithelium is extremely sensitive to circulatory
changes, and that compression of the renal artery for only a few minutes
causes serious disturbance.
The circulation of the kidney is remarkably influenced by reflex stimuli
coming from the skin. Exposure to cold causes heightened blood-pressure
within the kidneys and increased secretion of urine. Bradford has shown that
after excision of portions of the kidney, to as much as one-third of the total
weight, there is a remarkable increase in the flow of urine.
Cong^estion of the Kidneys. — (1) Active Congestion; Hyperemia. —
Acute congestion of the kidney is met with in the early stage of nephritis,
whether due to cold or to the action of poisons and severe irritants. Turpen-
tine, cubebs, cantharides, and copaiba are all stated to cause extreme hyper-
semia of the organ. The most typical congestion of the kidney which we see
post mortem is that in the early stage of acute Bright's disease, when the organ
may be large, soft, of a dark color, and on section blood drips from it freely.
It has been held that in all the acute fevers the kidneys are congested,
and that this explained the scanty, high-colored, and often albuminous urine.
On the other hand, by Eoy's oncometer, Walter Mendelson has shown that
the kidney in acute fever is in a state of extreme anaemia, small, pale, and
bloodless; and that this anaemia, increasing with the pyrexia and interfering
with the nutrition of the glomerular epithelium, accounts for the scanty, dark-
colored urine of fever and for the presence of albumin. In the prolonged
fevers, however, it is probable that relaxation of the arteries again takes place.
Certainly it is rare to find post mortem such a condition of the kidney as is
described by Mendelson. On the contrary, the kidney of fever is commonly
swollen, the blood-vessels are congested, and the cortex frequently shows traces
of cloudy swelling. However, the circulatory disturbances in acute fevers are
probably less important than the irritative effects. of either the specific agents
of the disease or the products produced in their growth or in the altered metab-
olism of the tissues. The urine is diminished in amount, and may contain
albumin and tube-casts, sometimes much of the former and few of the latter.
(2) Passive Congestion; Mechanical Hyperemia. — This is found in
cases of chronic disease of the heart or lung, with impeded circulation, and as
668 DISEASES OF THE KIDNEYS.
a result of pressure upon the renal veins by tumors, the pregnant uterus, or
ascitic fluid. In the cardiac kidne}', as it is called, the c3ranotic induration
associated with chronic heart-disease, the organs are enlarged and firm, the
capsule strips off, as a rule, readily, the cortex is of a deep red color, and the
pyramids of a purple red. The section is coarse-looking, the substance is very
firm, and resists cutting and tearing. The interstitial tissue is increased, and
there is a small-celled infiltration between the tubules. Here and there the
]\Ialpighian tufts have become sclerosed. The blood-vessels are usually thick-
ened, and there may be more or less granular, fatty, or hyaline changes in the
epithelium of the tubules. The condition is indeed a diffuse nephritis. The
urine is usually reduced, is of high specific gravity, and contains more or less
albumin. Hyaline tube-casts and blood-corpuscles are not uncommon. In
some cases (over half) with macroscopically no signs of chronic or acute
nephritis the urinary features lead to the diagnosis of acute nephritis
(Emerson). In uncomplicated cases of the c3'^anotic induration uraemia is
rare. On the other hand, in the cardiac cases with extensive arterio-sclerosis,
the kidneys are more involved and the renal function is likely to be disturbed.
IV. ANOMALIES OF THE URINARY SECRETION.
1. Anuria.
Total suppression of urine occurs under the following conditions :
(1) As an event in the intense congestion of acute nephritis. For a time
no urine may be formed ; more often the amount is greatly reduced.
(2) More commonly complete anuria is seen in subjects of renal stone,
fragments of which block both ureters; or as in a case recently reported by
Monod the calculus blocked the only kidney, the other being represented by a
shell of tissue. Sir William Eoberts calls the condition "latent ursmia."
There may be very little discomfort, and the symptoms are very unlike those
of ordinary urgemia. Convulsions occurred in only 5 of 41 cases (Herter) ;
headache in only 6 ; vomiting in only 13. Consciousness is retained ; the pupils
are usually contracted ; the temperature may be low ; there are twitchings and
perhaps occasional vomiting. Of 41 cases in the literature, 35 occurred in
males. Of 36 cases in which there was absolute anuria, in 11 the condition
lasted more than four days, in 18 cases from seven to fourteen daj'^s, and in
7 cases longer than fourteen days (Herter).
(3) Cases occur occasionally in which the suppression is prerenal. The
following are among the more important conditions with which this form of
anuria may be associated (Hensley) : Fevers and inflammations; acute poison-
ing by phosphorus, lead, and turpentine; in the collapse after severe injuries
or after operations, or, indeed, after the passing of a catheter; in the collapse
stage of cholera and yellow fever ; and, lastly, there is an hysterical anuria, of
which Charcot reports a eas^ in which the suppression lasted for eleven daj^s.
Bailey reports the ease of a young girl, aged eleven, inmate of an orphan
asylum, who passed no urine from Octol^er 10th to December 12th (when 8
ounces were withdrawn), and again from this date to March 1st! The ques-
tion of hysterical deception was considered in the case.
A patient may live for from ten days to two weeks vith complete sup-
ANOMALIES OF THE URINARY SECRETION. 669
pression. In Polk's ease, in which the only kidney was removed, the patient
d eleven days. It is remarkable that in many instances there are no toxic
features. Adams reports a case of recovery after nineteen days of suppression.
In the obstructive cases surgical interference should be resorted to. In
the non-obstructive cases, particularly when due to extreme congestion of
the kidney, cupping over the loins, hot applications, free purging, and sweat-
ing with pilocarpine and hot air are indicated. When the secretion is once
started diuretin often acts well. Large hot irrigations, with normal salt solu-
tion, with Kemp's double-current rectal tubes, should be tried, as they are
stated to stimulate the activity of the kidneys in a remarkable way.
2. HEMATURIA.
Etiology. — The following division may be made of the causes of hsema-
turia :
(1) General Diseases. — The malignant forms of the acute specific fevers.
Occasionally in leukaemia hgematuria occurs.
(2) Renal Causes. — Acute congestion and inflammation, as in Bright's
disease, or the effect of toxic agents, such as turpentine, carbolic acid, Sind^^^f\^
cantharides. When the carbolic spray was in use many surgeons suffered from . j
haematuria in consequence of this poison. Renal infarction, as in ulcerative '^'j*'**^
endocarditis. New growths, in which the bleeding is usually profuse. In tuber- <'!;«>•.*-
culosis at the onset, when the papillae are involved, there may be bleeding. /^„*^
Stone in the kidney is a frequent cause. Parasites : The Filaria sanguinis liom- ^
inis and the BilJiarzia cause a form of haematuria met with in the tropics. /V****
The echinocoecus is rarely associated with haemorrhage. It is sometimes met
with in floating kidney. /
Unilateral renal hcematuria has been described by Senator, Eshner, and
others. The cases are not uncommon, as 48 cases have been tabulated by
Eshner. In nearly all the diagnosis of calculus or neoplasm had been made.
In 16 cases nothing was found at operation. Displacement was present in 6
cases, alteration in the pelvis of the kidney in 9, other destructive lesions of
the kidney in 11. The condition has been termed by Senator renal haemophilia,
but renal " epistaxis," as suggested by Gull, is a more appropriate term.
(3) Affections of the Urinary Passages. — Stone in the ureter, tumor
or ulceration of the bladder, the presence of a calculus, parasites, and, very
rarely, ruptured veins in the bladder. Bleeding from the urethra occasion-
ally occurs in gonorrhoea and as a result of the lodgment of a calculus. Recur-
ring hasmaturia may be an early symptom in enlarged prostate. An unusual
cause is the painful, villous tumor of the renal pelvis, of which Savory and
ISTash report a remarkable case and have collected 49 others from the literature.
It would be difficult to recognize the condition from stone.
(4) Traumatism. — Injuries may produce bleeding from any part of the
urinary passages. By a fall or blow on the back the kidney may be ruptured,
and this may be followed by very free bleeding ; less commonly the blood comes
from injury of the bladder or of the prostate. Blood from the urethra is
frequently due to injury by the passage of a catheter, or sometimes to falls.
Transient haematuria follows all operations on the kidney.
The malarial haematuria has already been considered in the section on
paludism.
670 DISEASES OF THE KIDNEYS.
Diagnosis. — The diagnosis of hj^niaturia is usually eas}^ The color of the
urine varies from a light smok}^ to a l^right red^ or it may have a dark porter
color. Examined with the microscope^ the blood-corpuscles are readily recog-
nized, either plainly visible and retaining their color, in which case they are
usually crenated, or simply as shadows. In ammoniacal urine or urines of
low specifi-C gravity the haemoglobin is rapidly dissolved from the corpuscles,
but in normal urine they remain for many hours unchanged.
It is important to distinguish between blood coming from the bladder
and from the kidneys, though this is not always easy. From the bladder the
blood may be found only with the last portions of urine, or only at the ter-
mination of micturition. In haemorrhage from the kidnej's the blood and urine
are intimately mixed. Clots are more commonly found in. the blood from the
kidneys, and may form moulds of the pelvis or of the ureter. When the seat
of the bleeding is in the bladder, on washing out this organ, the water is more
or less blood-tinged; but if the source of the bleeding is higher, the water
comes away clear. In many instances it is difficult to settle the question by
the examination of the urine alone, and the symptoms and the physical signs
must also be taken into account. Cj'stoscopic examination of the bladder, pay-
ing especial attention to the urine flowing from each ureteral orifice, and
catheterization of the ureters are aids in the diagnosis of doubtful cases.
3. HEMOGLOBINURIA.
This condition is characterized by the presence of blood-pigment in the
urine. The blood-cells are either absent or in insignificant nmnbers. The
coloring matter is not hgematin, as indicated by the old name, hcematinuria,
nor in reality always hsemoglobin, but it is most frequently methsemoglobin.
The urine has a red or bro'^mish-red, sometimes quite black color, and usually
deposits a very heav}^ brownish sediment. "When the haemoglobin occurs only in
small quantities, it ma}^ give a lake or smoky color to the urine. Microscopical
examination shows the presence of granular pigment, sometimes fragments of
blood-disks, epithelium, and very often darkly pigmented urates. The urine
is also albuminous. The number of red blood-corpuscles bears no proportion
whatever to the intensity of the color of the urine. Examined spectroscop-
ically, there are either the two absorption bands of oxyhgemoglobin, which is
rare, or, more commonly, there are the three absorption bands of methgemo-
globin, of which the one in the red near C is characteristic' Two clinical
groups may be distinguished.
(1) Toxic Hsemoglobinuria. — This is caused by poisons which produce
rapid dissolution of the blood-corpuscles, such as potassium chlorate in large
doses, pyrogallic acid, carbolic acid, arseniuretted hydrogen, carbon monoxide,
naphthol, and muscarine ; also the poisons of scarlet fever, yellow fever, typhoid
fever, malaria, and s}^hilis. According to Bastianelli, hsemoglobinuria due
to the administration of quinine never occurs excepting in patients who are
suffering or who have recently suffered from malarial fever. It has also fol-
lowed severe burns. Exposure to excessive cold and violent muscular exertion
are stated to produce haemoglobinuria. A most remarkable toxic form occurs
in horses, coming on with great suddenness and associated with paresis of the
hind legs. Death may occur in a few hours or a few days. The animals are
attacked only after being stalled for some days and then taken out and driven,
ANOMALIES OF THE URINARY SECRETION. 671
particularly in cold weather. The form of hemoglobinuria from cold and
exertion is extremely rare. No instance of it, even in association with frost-
bites, came under my observation in Canada. Blood transfused from one
mammal into another causes dissolution of the corpuscles with the produc-
tion of hgemoglobinuria ; and, lastly, there is the epidemic hcemoglohinuria of
the new-born, associated with jaundice, cyanosis, and nervous symptoms.
(3) Paroxysmal Hsemoglobinuria. — This rare disease is characterized by
the occasional passage of bloody urine, in which the coloring matter only is
present. It is more frequent in males than in females, and occurs chiefly in
adults. It seems specially associated with cold and exertion, and has often
been brought on, in a susceptible person, by the use of a cold foot-bath. Par-
oxysmal hemoglobinuria has been found, too, in persons subject to the vari-
ous forms of Eaynaud's disease. Many regard the relation between these two
affections as extremely close; some hold that they are manifestations of one
and the same disorder. Druitt, the author of the well-knoAvn Surgical Vade-
mecum, has given a graphic description of his sufferings, which lasted for many
years, and were accompanied with local asphyxia and local syncope. The
connection, however, is not very common. In only one of the cases of Eay-
naud's disease which I have seen was paroxysmal hemoglobinuria present, and
in it epileptic attacks occurred at the same time. The relation of the disease
to malaria has been considered.
The attacks may come on suddenly after exposure to cold or as a result
of mental or bodily exhaustion. They may be preceded by chills and pyrexia.
In other instances the temperature is subnormal. There may be vomiting and
diarrhoea. Pain in the lumbar region is not uncommon. The hemoglobinuria
rarely persists for more than a day or two — sometimes, indeed, not for a day.
There are instances in which, even in the course of a single day, there have
been two or three paroxysms, and in the intervals clear urine has been passed.
Jaundice has been present in a number of cases. The cases are rarely if ever
fatal.
The essential pathology of the disease is unknown, and it is difficult to
form a theory which will meet all the facts — ^particularly the relation with Eay-
naud's disease, which is rightly regarded as a vaso-motor disorder. Increased
hemolysis and solution of the hemoglobin in the blood-serum (hemoglobi-
nemia) precedes, in each instance, the appearance of the coloring matter in the
urine. A full discussion of the subject is to be found in F. Chvostek's mono-
graph. Blanc regards it as distinctly nervous in origin.
Treatment. — In all forms of hematuria rest is essential. In that produced
by renal calculi the recumbent posture may suffice to check the bleeding. Full
doses of acetate of lead and opium should be tried, then ergot, gallic and
tannic acid, and the dilute sulphuric acid. The oil of turpentine, which is
sometimes recommended, is a risky remedy in hematuria. Extr. hamamelis
virgin, and extr. hydrastis canad. are also recommended. Cold may be applied
to the loins or dry cups in the lumbar region. Incision of the kidney has
cured the so-called renal epistaxis.
The treatment of paroxysmal hemoglobinuria is unsatisfactory. Amyl
nitrite will sometimes cut short or prevent an attack (Chvostek). During the
paroxysm the patient should be kept warm and given hot drinks. Quinine is
recommended in large doses, on the supposition — as yet unwarranted — that the
672 DISEASES OF THE KIDNEYS.
disease is specially connected Tvitli malaria. If there is a s}^liilitic history,
iodide of potassium in full doses may be tried. In a warm climate the attacks
are much less frequent.
4. Albumixukia.
" Reasons drawn from the urine are as brittle as the urinal " is a dictum of
Thomas Fuller peculiarly appropriate in connection with this subject.
The presence of albumin in the urine, formerly regarded as indicative of
Briglifs disease, is now recognized as occurring under many circumstances
without the existence of serious organic change in the kidney. Two groups
of cases may be recognized — those in which the kidneys show no coarse lesions,
and those in which there are evident anatomical changes.
Albumimiria without Coarse Renal Lesions. — (a) Functional^ so-called
Physiological Albumixueia. — In a normal condition of the kidney only
the water and the salts are allowed to pass from the blood. When albuminous
substances transude there is probably disturbance in the nutrition of the epi-
thelium of the capillaries of the tuft, or of the ceUs surrounding the glome-
rulus. This statement is still, however, in dispute, and Senator and others
hold that there is a plwsiological albuminuria which may follow muscular
work, the ingestion of food rich in albumin, violent emotions, cold bathing,
and dyspepsia. But on one point all agree, that the cause must be some-
thing unusual and excessive, as an unusually hard tramp, a football match,
a race, etc. The presence of albumin in the urine, in any form and under
any circumstance, may be regarded as indicative of change in the renal or
glomerular epithelium, a change, however, which may be transient, slight, and
unimportant, depending upon variations in the circulation or upon the irri-
tating effects of substances taken with the food or temporarily jDresent, as in
febrile states.
Albuminuria of adolescence and cyclic albuminuria, in which the albu-
min is present only at certaiu times during the day — orthostatic albuminuria
— are interesting forms. A majority of the cases occur in young persons —
boys more commonly than girls — and the condition is often discovered acci-
dentally. These are often the children of neurotic parents, and have well-
marked vasomotor instability. Some cases last only during puberty, some
throughout life. Erlanger and Hooker have shown that the albumin is ex-
creted only during periods with low pulse pressure (difference between the
diastolic and systolic pressures). The urine, as a rule, contains only a very
small amount of albumin, but in some instances large quantities are present.
The most striking feature is the variability. It may be absent in the morn-
ing and present only after exertion; or it ma}^ be greatly increased after
taking food, particularly proteids. Even the change to the upright position
(orthostatic) may suffice to cause it, and in such cases there may be tension on
the renal veins by increase of the lumbar curve, since it has been shown that a
spinal jacket will prevent the appearance of the albumin. The quantity of
urine may be but little, if at all, increased, the specific gravity is usually nor-
mal, and the color may be high. Occasionally hyaline casts may be found,
and in some instances there has been transient glycosuria. As a rule, the pulse
is not of high tension and the second aortic sound is not accentuated.
Various forms of this affection have been recognized by writers, such
ANOMALIES OF THE URINARY SECRETION. 673
as neurotic, dietetic, cyclic, intermittent, and paroxysmal — names which indi-
cate the characters of the different varieties. A large proportion of the cases
get well after the condition has persisted for a variable period. This in itself
is an evidence that the changes, whatever their nature, are transient and slight.
In these instances the albumin exists in small quantity, tube-casts are rarely
present, and the arterial tension is not increased. In a second group the albu-
min is more persistent, the amount is larger, though it may vary from day
to day, and the pulse tension is increased. In such instances the per-
sistent albuminuria probably indicates actual organic change in the kidney.
(&) Febrile Albuminuria. — Pyrexia, by whatever cause produced, may
cause slight albuminuria. The presence of the albumin is due to slight
changes in the glomeruli induced by the fever, such as cloudy swelling, which
can not be regarded as an organic lesion. It is extremely common, occurring
in pneumonia (in about 70 per cent of our cases), diphtheria, typhoid fever
(about 60 per cent of our cases), malaria, especially the sestivo-autumnal type,
and even in the fever of acute tonsillitis. The amount of albumin is slight,
and it usually disappears from the urine with the cessation of the fever.
Hyaline and even epithelial casts accompany the condition.
(c) H^Mic Changes. — Purpura, scurvy, chronic poisoning by lead or
mercury, syphilis, leukeemia, and profound anaemia may be associated with
slight albuminuria. Abnormal ingredients in the blood, such as bile-pigment
and sugar, may cause the passage of small amounts of albumin.
The transient albuminuria of pregnancy may belong to this h^mic group,
although in a majority of such cases there are 'changes in the renal tissue.
Albumin may be found sometimes after the inhalation of ether or chloroform.
(d) Nervous System. — Albuminuria occurs in certain affections of the
nervous system. This so-called neurotic albuminuria is seen after an epileptic
seizure and in apoplexy, tetanus, exophthalmic goitre, and injuries of the head.
Albuminuria with Definite Lesions of the Urinary Organs. — (a) Conges-
tion of the kidney, either active, such as follows exposure to cold and is asso-
ciated with the early stages of nephritis, or passive, due to obstructed outflow
in disease of the heart or lungs, or to pressure on the renal veins by the preg-
nant uterus or tumors.
(&) Organic disease of the kidneys — acute and chronic Bright's disease,
amyloid and fatty degeneration, suppurative nephritis, and tumors.
(c) Affections of the pelvis, ureters, and bladder, when associated with
the formation of pus.
Tests for Albumin. — ^Both morning and evening urine should be examined,
and in doubtful cases at least three specimens. If turbid, the urine should be
filtered, though turbidity from the urates is of no moment, since it disappears
at once on the application of heat.
Heat and Nitric-acid Test. — The urine is boiled in a test-tube over a spirit-
lamp, and a drop of nitric acid is then added. If a cloudiness occurs on boil-
ing, it may be due to phosphates, which are dissolved on the addition of an
acid. Persistence of the cloudiness indicates albumin.
Heller's Test. — A small quantity of fuming nitric acid is poured into the
test-tube, and with a pipette the urine is allowed to flow gently down the side
upon the acid. At the line of junction of the two fluids, if albumin is present,
a white ring is formed. This contact method is trustworthy, and, for the
674: DISEASES OF THE KIDNEYS.
routine clinical ^vork. is prolmbly the most satisfactory. A diffused liaze. due
to mucin (nucleo-albumin), is sometimes seen just above the white ring of
albumin: and in very concentrated urines, or after the taking of balsamic
remedies, a slight cloudiness may be due to urates or uric acid, which clears
on heating or warming. A colored ring at the junction of the acid and the
urine is due to the oxidation of tlie coloring matters in the urine.
Ferrocyanide-of -potassium and Acetic-acid Test. — Fill an ordinary test-
tube half full of urine, and add 5 or 6 cc. of potassium-ferrocyanide solution
(1 in 20). Thoroughly mix the urine and reagent and add 10 to 15 drops of
acetic acid. If albumin be present, a cloudiness varying in degree accord-
ing to the amount of albumin will be produced. This is a very reliable
test, as it precipitates all forms of albumin, acid and alkaline, but does not
precipitate mucin, peptones, phosphates, urates, vegetable alkaloids, or the
pine acids.
Sir William Eoberts strongly recommends the magnesium-nitric test. One
volume of strong nitric acid is mixed with five volumes of the saturated solu-
tion of sulphate of magnesium. This is used in the same way as the nitric
acid in Hellers test.
Picric acid, introduced Ijy George Johnson, is a delicate and useful test
for albumin. A saturated solution is used and employed as in the contact
method. It has been urged against this test that it throws down the mucin,
peptones, and certain vegetable alkaloids, but these are dissolved by heat.
For minute traces of albumin the trichloracetic acid may be used, or Mil-
lard's fluid, which is extremely delicate and consists of glacial carbolic acid
(95 per cent), 2 drachms; pure acetic acid, T drachms; liquor potassge, 2 ounces
6 drachms.
A quantitative estimate of the albumin can be made by means of Esbach's
tube, but the rough method of heating and boiling a certain quantity of
acidulated urine in a test-tube and allowing it to stand, is often employed.
The depth of deposit can then be compared with the whole amount of urine,
and the proportion is expressed as a mere trace, almost solid — one-fourth, one-
half, and so on. This, of course, does not give an accurate indication of the
proportion of albumin in the total quantity of urine. For the more elabo-
rate methods the reader is referred to the works on urinalysis.
The above tests refer entirely to serum-albumin. Other albuminous sub-
stances occur, such as albumose, serum-globulin, peptones, and hemi-albumose
or propeton. They are not of much clinical importance.
Albumosuria. — Traces of albumoses are found in the urine in many febrile
diseases, as pneumonia, and in chronic suppuration, and have little clinical
significance.
Myelopathic Albumosuria, '' KaliJer's disease,'' is characterized by multi-
ple myelomata with persistent excretion of what is known as the Bence-Jones
body, a proteid discovered by him in 1848. There are between thirty-five and
forty cases on record (Anders and Boston. Lancet, 1903; Parkes Weber, Med.-
Chir. Trans., vol. Ixxxvi). Males above forty years of age are usually affected.
The Bence-Jones body does not appear ^vith other tumors of the bones. As
in a case which I saw with Hamburger, the persistent albumosuria may lead
to the diagnosis of multiple myelomata before any bone tumors can be felt.
The disease rims a fatal course. The simplest reaction is the white precipi-
ANOMALIES OF THE URINARY SECRETION. 675
tate formed on adding nitric acid to the urine; when boiled it disappears, to
reappear on cooling. As in one of Bradshaw's cases, the urine may be of a
milky white color when passed.
Globulin rarely occurs in the urine alone, but generally in association with
serum-albumin. The latter is usually present in greater quantity, but in severe
organic renal disease and in diabetes Maguire has found that the proportion
of globulin to albumin is often 2.5 to 1. Senator states that more globulin is
present with the lardaceous kidney than in other forms of nephritis. The
clinical significance of globulin is the same as that of serum-albumin.
Prognosis. — This depends, of course, entirely upon the caiise. Febrile
albuminuria is transient, and in a majority of the cases depending upon
heemic causes the condition disappears and leaves the kidneys intact. A trace
of albumin in a man over forty, with or without a few hyaline casts, is not
of much significance, except as an indication that his kidneys, like his hair,
are beginning to turn " gray " with age. In many instances the discovery is a
positive advantage, as the man is made to realize, perhaps, for the first time
that he has been living carelessly. I have discussed the question from this
standpoint in a paper with the paradoxical title " On the Advantages of a
Trace of Albumin and a few Tube-casts in the Urine of Men over Fifty Years
of Age" CN. Y. Med. Jour., vol. Ixxiv).
The persistence of a slight amount of albumin in young men without in-
creased arterial tension is less serious, as even after continuing for years it
may disappear. I have already spoken of the outlook in the so-called cyclic
albuminuria.
Practically in all cases the presence of albumin indicates a change of
some sort in the glomeruli, the nature, extent, and gravity of which it is
difficult to estimate ; so that other considerations, such as the presence of tube-
casts, the existence of increased tension, the general condition of the patient,
and the infiuence of digestion upon the albumin, must be carefully considered.
The physician is daily consulted as to the relation of albuminuria and
life assurance. As his function is to protect the interests of the company,
he should reject all cases in which albumin occurs in the urine. It is even
doubtful if an exception should be made in young persons with transient
albuminuria. ]S[aturally, companies lay great stress upon the presence or
absence of albumin, but in the most serious and fatal malady with which they
have to deal — chronic interstitial nephritis — the albumin is often absent or
transient, even when the disease is well developed. After the fortieth year,
from a standpoint of life insurance, the state of the arteries and the blood
pressure is far more important than the condition of the urine.
With reference to the significance of albuminuria in adults, I quite agree
with the following conclusions of F. C. Shattuck :
(1) Eenal albuminuria, as proved by the presence of both albumin and
casts, is ^auch more common in adults, quite apart from Bright's disease or
any obvious source of renal irritation, than is generally supposed.
(2) The frequency increases steadily and progressively with advancing age.
(3) This increase with age suggests the explanation that the albuminuria
is often an indication of senile degeneration.
(4) Though it can not be regarded as yet as absolutely proved, it is highly
probable that faint traces of albumin and hyaline and finely granular easts
676 DISEASES OF THE KIDNEYS.
of small diameter are often, especially in those past fifty years of age, of little
or no practical importance.
E. C. Cabot's studies also show that we have been laying altogether too
much stress on albumin and tube-casts as indicative of serious disease of the
kidneys.
5. Pyuria {Pus in the Urine).
Causes. — (1) Pyelitis and Pyelonephritis. — In large abscesses of the
kidney, pyonephrosis, the pus may be intermittent, while in calculous and
tuberculous pyelitis the p5airia is usually continuous, though varying in in-
tensity. In cases due to the colon or tubercle bacillus the urine is acid, in
those due to the proteus bacillus alkaline, while in the staphylococcus cases
the urine is either less acid than normal, or alkaline. In the pyelitis and
pyelonephritis following cystitis the urine is alkaline or acid, depending upon
the infecting micro-organism; more mucus, frequent micturition, and a pre-
vious bladder history are aids in diagnosis.
(2) Cystitis. — The urine is usually acid, especially in women, since the
colon bacillus is a very common cause of these infections. The pus and mucus
are more ropy, and triple phosphate crystals are found in the freshly passed
urine in the alkaline infections.
(3) Urethritis, particularly gonorrhoea. The pus appears first, is in
small quantities, and there are signs of local inflammation.
(4) In LEUCORRHCEA the quantity of pus is usually small, and large flakes
of vaginal epithelium are numerous. In doubtful cases, when leucorrhoea
is present, the urine should be withdrawn through a catheter.
(5) Eupture of Abscesses into the Urinary Passages. — In such cases
as pelvic or perityplitic abscess there have been previous symptoms of pus
formation. A large amount is passed within a short time, then the discharge
stops abruptly or rapidly diminishes within a few days.
Pus gives to the urine a white or yellowish-white appearance. On settling,
the sediment is sometimes ropy, the supernatant fluid usually turbid. In cases
due to urea-decomposing microbes (proteus bacillus, various staphylococci) the
odor may be ammoniacal even in fresh urine. Examination with the micro-
scope reveals the presence of a large number of pus-corpuscles, which are
usually, when the pus comes from the bladder, well formed; the protoplasm
is granular, and often shows many translucent processes.
The only sediment likely to be confounded with pus is that of the phos-
phates; but it is whiter and less dense, and is distinguished immediately by
microscopical examination or by the addition of acid.
With the pus there is always more or less epithelium from the bladder
and pelves of the kidneys, but since in these situations the forms of cells are
practically identical, they afford no information as to the locality from which
the pus has come.
The treatment of pus in the urine is considered under the conditions in
which it occurs.
6. ChYLURIA ISTON-PARASITIC.
This is a rare affection, occurring in temperate regions and unassoeiated
with the Filaria hancrofti. The urine is of an opaque white color; it resem-
ANOMALIES OF THE URINARY SECRETION. 677
bles milk closely, is occasionally mixed with blood (haematochyluria), and
sometimes coagulates into a firm, jelly-like mass. In other instances there
is at the bottom of the vessel a loose clot which may be distinctly blood-tinged.
Under the microscope the turbidity seems to be caused by numerous minute
granules — more rarely oil droplets similar to those of milk. In Montreal I
made the dissection in a case of thirteen years' duration and could find no
trace of parasites (see Hertz, Med.-Chir. Soc. Trans., 1907).
7. LiTHUEiA (Lithcemia; Lithic-acid Diathesis).
The general relations of uric acid have already been considered in speak-
ing of gout.
Occurrence in the TTrine. — The uric acid occurs in combination chiefly
with ammonium and sodium, forming the acid urates. In smaller quan-
tities are the potassium, calcium, and lithium salts. The uric acid may be
separated from its bases and crystallizes in rhombs or prisms, which are usu-
ally of a deep red color, owing to the staining of the urinary pigments. The
sediment formed is granular and the groups of crystals look like grains of
Cayenne pepper. It is very important not to mistake a deposit of uric acid
for an excess. The deposition of numerous grains in the urine within a few
hours after passing is more likely to be due to conditions which diminish the
solvent power than to increase in the quantity. Of the conditions which
cause precipitation of the uric acid Eoberts gives the following: ^^ (1) High
acidity; (2) poverty in mineral salts; (3) low pigmentation; and (4) high
percentage of uric acid." The grade of acidity is probably the most impor-
tant element.
In health the weight of uric acid excreted bears a fairly constant ratio to
the weight of urea eliminated. According to von Noorden, the average ratio
is 1 to 50, while the average ratio of the nitrogen of uric acid to the total
nitrogen eliminated in the urine is 1 to 70. In several of the cases of gout in
my wards Futcher found that in the intervals between the acute arthritic
attacks the uric acid was reduced to a much greater extent than the urea,
so that the ratio of the former to the latter often varied between 1 to 300 up
to (in one case) 1 to 1,500, a return to about the normal proportions occurring
during the acute attacks.
More common is the precipitation of amorphous urates, forming the so-
called brick-dust or lateritious deposit, which has a pinkish color, due to
the presence of urinary pigment. It is composed chiefly of the acid sodium
urates. It occurs particularly in very acid urine of a high specific gravity.
As the urates are more soluble in warm solutions, they frequently deposit as
the urine cools. Here, too, the deposition does not necessarily, indeed usually
does not, mean an excessive excretion, but the existence of conditions favoring
the deposit.
Lithaemia. — In addition to what has already been said under gout, we may
consider here the hypothetical condition known as lithtemia, or the uric-acid
diathesis. Murchison introduced the term to designate certain symptoms due,
as he supposed, to functional disturbance of the liver. Not only have his
views been widely adopted, but, as is so often the case when we give the rein
to theoretical conceptions of disease, the so-called manifestations of this state
have so multiplied that some authors attribute to this cause a considerable pro-
678 DISEASES OF THE KIDNEYS.
portion of the ailments affecting the various systems of the body. Thus one
writer enumerates not fewer than forty-one separate morbid conditions asso-
ciated with lithaemia, and one of them astigmatism against the rule ! From
our lack of knowledge of the mode of formation and elimination of uric acid
it is very evident that the physiology of the subject must be widely extended
before we are in a position to draw safe conclusions. Thus it is by no means
sure that, as Murchison supposed, the essential defect is a functional dis-
order of the liver, disturbing the metabolism of the albuminous ingredients, nor
is it at all certain that the only offending substance is uric acid. In the
present imperfect state of knowledge it is impossible with any clearness to
define the pathology of the so-called uric-acid diathesis. We may say that
certain s}Tnptoms arise in connection with defective food or tissue metabolism,
more particularly of the nitrogenous elements. Deficient oxidation is prob-
ably the most essential factor in the process, with the result of the formation
of less readily soluble and less readily eliminated products of retrograde meta-
morphosis. This faulty metabolism if long continued may lead to gout, with
uratic deposits in the joints, acute inflammations, and arterial and renal dis-
ease. In a large group of cases the disturbed metabolism produces high ten-
sion in the arteries (probabh' as a direct sequence of interference with the
capillary circulation) and ultimately degenerations in various tissues, par-
ticularly the scleroses.
Overeating and overdrinking, when combined with deficient muscular ex-
ercise, lie at the basis of this nutritional disturbance. The symptoms which
are believed to characterize the uric-acid diathesis have already been briefly
treated of under the section on irregular gout, and the question of diet and
exercise has also been there considered.
8. OXALURIA.
The discovery of calcium-oxalate crystals in the urine by Donne in 1838
led to the description of the so-called oxalic-acid diathesis. It is claimed that
all the oxalic acid found in the urine is taken into the body with the food
(Dunlop). In health none, or only a trace, is formed in the body. The
amount fluctuates with the quantity of food taken, and is usually below 10
milligrammes daily (H. Baldwin). It seems to be formed in the body when
there is an absence of free hydrochloric acid in the gastric juice, and in
connection with excessive fermentation in the intestines. It never forms a
heavy deposit, but the crystals — ^usually octahedral, rarely dumb-bell-shaped
— collect in the mucus-cloud and on the sides of the vessel.
When in excess and present for any considerable time, the condition is
known as oxaluria, the chief interest of which is in the fact that the crystals
may be deposited before the urine is voided, and form a calculus. It is held
by many that there is a special diathesis associated with its presence in excess
and manifested clinically by dyspepsia, particularly the nervous form, irrita-
bility, depression of spirits, lassitude, and sometimes marked hypochondriasis.
There may be in addition neuralgic pains and the general symptoms of neuras-
thenia. The local and general symptoms are probably dependent upon some
disturbance of metabolism of which the oxaluria is one of the manifesta-
tions. It is a feature also in many gouty persons, and in the condition called
lithgemia.
ANOMALIES OF THE URINARY SECRETION. 679
9. Cystinukia.
Stadthagen claims that normal urine does not contain cystin, though Bau-
mann and Goldmann succeeded in separating it in very small quantities from
healthy urine as a benzoyl compound. It is associated with elimination of
diamines both in the fasces and urine. It is very rarely met with, and,. its
chief interest is owing to the fact that it may form calculi, sometimes in large
numbers. It is a sort of chemical malformation (Garrod), and its presence
has been determined in many members of the same family. The condition
appears sometimes to be hereditary. As it contains sulphur, it is thought to
be formed from the taurin of the bile. The colorless hexagonal crystals are
very characteristic in appearance, and yet uric acid may assume the same
form. Cystin is soluble in ammonia and reprecipitated by acetic acid.
10. Phosphaturia.
The phosphoric acid is excreted from the body in combination with potas-
sium, sodium, calcium, and magnesium, forming two classes, the alkaline
phosphates of sodium and potassium and the earthy phosphates of lime and
magnesia. The amount of phosphoric acid (P2O5) excreted in the twenty-
four hours varies, according to Hammarsten, between 1 and 5 grammes, with
an average of 2.5 grammes. It is derived mainly from the phosphoric acid
taken in the food, but also in part as a decomposition product from nuclein,
protagon, and lecithin. Of the alkaline phosphates, those in combination with
sodium are the most abundant. The alkaline phosphates of the urine are
more abundant than the earthy phosphates.
Of the earthy pJiosphates, those of lime are abundant, of magnesium scanty.
In urine which has undergone the ammoniacal fermentation, either inside
or outside the body, there is in addition the ammonio-magnesium or triple
phosphate, which occurs in triangular prisms or in feathery or stellate crys-
tals; hence the term given to this form of stellar phosphates. The earthy
phosphates occur as a sediment in the urine when the alkalinity is due to a
fixed alkali, or under certain circumstances the deposit may take place within
the bladder, and then the phosphates are passed at the end of micturition as
a whitish fluid, which is popularly confounded with spermatorrhoea. Eecent
study of these cases with symptoms of neurasthenia and a phosphate sediment
in the fresh urine would indicate an abnormality in the calcium metabolism,
an absolute increase of this with a decrease of the phosphoric acid. The cal-
cium phosphate may be precipitated by heat and produce a cloudiness which
may be mistaken for albumin, but is at once dissolved upon making the urine
acid. This condition is very frequent in persons suffering from dyspepsia or
from debility of any kind. The phosphates may be in great excess, rising in
the twenty- four hours to from 7 to 9 grammes (Tessier), whereas the normal
amount is not more than 2.5 grammes. And, lastly, the phosphates may be
deposited in urine which has undergone decomposition, in which the carbonate
of ammonia from the urea combines with the magnesium phosphates, forming
the triple salt. This is seen in cystitis, due to a urea-decomposing microbe.
The clinical significance of an excess of phosphates, to which the term
phosphaturia is applied, has been much discussed. It must be remembered
680 DISEASES OF THE KIDNEYS.
that a deposit does not necessarily mean an excess^ to . determine which a
careful anah'sis of the twenty-four hours' secretion should be made. It has
long been thought that there is a relation between the activity of the nerve-
tissues and the output, of phosphoric acid ; but the question can not 3'et be con-
sidered settled. The amount is increased in wasting diseases, such as phthi-
sis, acute yellow atrophy of the liver, leukaemia, and severe anaemia, whereas
it is diminished in acute diseases and during pregnancy.
In a condition termed by Tessier, Ealfe, and others, phosphatic diabetes
there are polyuria, thirst, emaciation, and a great increase in the excretion
of phosphates, which may be as much as from T to 9 grammes in the day.
The urine is usually acid and free from sugar: the patients are nervous; in
some instances sugar has been present in the urine, and in others it subse-
quently makes its appearance.
11. IXDICAXUEIA.
The substance in the urine which has received this name is the indoxyl-
sulphate of potassium, in which form it appears in the urine and is color-
less. When concentrated acids or strong oxidizing agents are added to the
urine, this substance is decomposed and the indigo set free. It is present only
in small quantities in healthy urine. It is derived from the indol, a product
formed in the intestine by the decomposition of the albumin under the influ-
ence of bacteria. When absorbed, this is oxidized in the tissues to indoxyl,
which combines with the potassium sulphate, forming the above-named sub-
stance.
The quantity of indican is diminished on a milk (and a Kefir) diet. It
is increased in all wasting diseases, as carcinoma, and whenever any large
quantities of albuminous substances are undergoing rapid decomposition, as
in the severer forms of peritonitis and empyema. It is not usually increased in
constipation, although it may be present in large amounts with no other dis-
coverable cause, but is met with in ileus, particularly in obstruction of the
small intestine. Indican has occasionally been found in calculi. Though, as
a rule, the urine is colorless when passed, there are instances in which the
decomposition has taken place within the body, and a blue color has been
noticed immediately after the urine was voided. Sometimes, too, in alka-
line urine on exposure there is a bluish film on the surface. Methylene blue,
a coloring matter for candy, etc., must be excluded.
To test for indican, place 4 or 5 ce. of nitric or hydrochloric acid in a
test-tube; boil, and add an equal quantity of urine. A bluish ring develops
at the point of contact. Add 1 or 2 cc. of chloroform and shake the test-
tube; on separation the chloroform has a violet or bluish color due to the
presence of indican. Obermayer's reagent is also good.
12. Melanueia.
Black urine may be dark when passed or may become so later. In the
following conditions melanuria may occur: (1) Jaundice. Only in very
chronic cases of deeply bronzed icterus do we see the urine quite dark, due to
the presence of large quantities of biliverdin. (2) Haematuria and haemo-
globinuria. Here it is a matter of the exaggeration of the smoky tint du-e to
ANOMALIES OF THE URINARY SECRETION. 681
the presence of blood in various quantities. (3) Haematoporphyrinuria, in
which the color ranges from a dark pink to blackness. The presence of the
haematoporphyrin is due to the toxic action of sulphonal or its allies, and
occurs when the drug has been taken for long periods. (4) Melanuria, in
which the urine has, as a rule, the normal color when passed, and on
standing becomes black as ink. In some instances it is black when passed.
Melanuria of this type only occurs with the presence of melanotic tumors.
(5) Alkaptonuria and ochronosis. (See section on Alkaptonuria.) (6) In-
dicanuria. When rich in indoxyl sulphate the urine is brown in color, or
becomes so after standing, due to the oxidation products of indol. This is by
far the most common cause of black urine, and in any disease leading to an
abundant secretion of indican, as in intestinal obstruction, etc., black urine
may be passed. As Garrod suggests, it is probable that the black urine in
cases of tuberculosis is of an allied nature. (7) After certain articles of
diet and drugs. Some dark-colored vegetable pigments, as black cherries
and plums and bilberries, cause darkening qf the urine. Eesorcin may do the
same. Carboluria is by no means uncommon, and was frequently seen in the
days of the antiseptic spray. It has been ascribed to hydrochinone formed
from phenol. Napthalene, creasote, and the salicylates may cause darken-
ing of the urine, or even blackness. For a full consideration of the subject
of black urine, see A. E. Garrod, The Practitioner, March, 1904.
13. Alkaptonuria and Ochronosis.
" Alkaptonuria is not the manifestation of a disease, but is rather of the
nature of an alternative course of metabolism, harmless and usually congen-
ital and lifelong" (Garrod). Of 40 known examples, 19 occurred in seven
families, and several were the offspring of first cousins (Garrod). There are
two points of clinical interest. The alkapton urine reduces Fehling's solution,
and diabetes may be suggested, but it does not ferment, and it is optically
inactive. The linen may be stained by the urine, which in some cases is dark
when passed. In 1866 Virchow recorded a case of blackening of the carti-
lages and ligaments — ochronosis. Cases have since been described post mor-
tem. In my cases the cartilages of the ear were blackened, the sclerotics were
stained a brownish-black color, and in one there was a butterfly-shaped patch
of ebony black pigmentation of the skin of the nose and cheeks. A chronic
arthritis usually accompanies the condition, and in my cases (brothers) there
was a curious " goose-gait," due to a bend in the lumbar region. Langstein
and Meyer conclude that alkaptonuria is an anomaly of metabolism with the
excretion in the urine of intermediate products. These are aromatic bodies,
homogentisic and uroleucic acid, and originate from the destruction of the
albuminous elements of the food and of the organs.
14. Pneumaturia.
Gas may be passed with the urine —
1. After mechanical introduction of air in vesical irrigation or cysto-
scopic examination in the knee-elbow position.
3. As a result of the introduction of gas-forming organisms in catheteri-
zation or other operation. Glycosuria has been present in a majority of the
682 DISEASES OF THE KIDNEYS.
cases. The yeast fungus, the colon bacillus, and the bacillus aerogenes cap-
sulatus have been found.
3. In cases of vesico-enteric fistula.
In gas production -n-ithin the bladder the s}Taptoms are those of a mild
cystitis, with the passage of gas at the end of micturition, sometimes with
a loud sound. The diagnosis is readily made by causing the patient to urinate
in a bath or by plunging the end of the catheter under water.
15. Other Suestances.
LiPURiA. — Fat in the urine, or lipuria, occurs, according to Halliburton,
first, without disease of the kidneys, as in excess of fat in the food, after the
administration of cod-liver oil, in fat embolism occurring after fractures, in
the fatty degeneration in phosphorus poisoning, in prolonged suppuration, as
in phthisis and pygemia, in the lipgemia of diabetes mellitus ; secondly, with dis-
ease of the kidneys, as in the fatty stage of chronic Bright's disease, in whicli
fat casts are sometimes present, and, according to Ebstein, in pyonephrosis;
and, thirdly, in the affection known as chyluria. The urine is usually turbid,
but there may be fat drops as well, and fatty crystals have been found.
LiPACiDUEiA is a term applied by von Jaksch to the condition in which
there are volatile fatty acids in the urine, such as acetic, but}Tic, formic, and
propionic acid.
AcETOxuEiA. — Yon Jaksch distinguishes the following forms of patholog-
ical acetonuria: The febrile, the diabetic, the acetonuria with certain forms
of cancer, the form associated with inanition, acetonuria in psychoses, and
the acetonuria which results from auto-intoxication. It is doubtful, however,
whether the s}Tnptoms in these are really due to the acetone. It may be the
substances from which this is formed, particularly the diacetic acid or the
^ -oxy-butyric acid. The odor of the acetone may be marked in the breath
and evident in the urine. The tests have been given in the section on diabetes.
Diacetic acid is probably never present in the urine in health. With
a solution of ferric chloride it gives a Burgundy-red color. A similar reac-
tion is given by acetic, formic, and oxy-but}Tic acids; it may be present in
the urine of patients who are taking antipyrin, thallin, and the salicylates.
Hammarsten states that if the reaction be due to the presence of diacetic acid,
it will not be obtaiued in carrying out the test with a second specimen of urine
which has been boiled and allowed to cool. The ethereal extract of the acidu-
lated urine gives the reaction if diacetic acid be present, whereas the other
substances which may be mistaken for diacetic acid are insoluble in ether.
^-oxT-BUTTEic ACID is believed by Stadelmann, Kiilz, and Minkowski to
be the cause of diabetic coma. It is a product of the decomposition of the
tissue albumins, and from it diacetic acid is readily formed by oxidation. Its
tests have already been given.
Choluria and glycosuria have already been considered under jaundice and
diabetes.
H^MATOPOEPHYRiN Occasionally occurs in the iiririe. It was first recog-
nized by Hoppe-Seyler. ]S3"encki and Sieler determined its exact formula, and
the former demonstrated that the only chemical difference between hjematia
and hffimatoporph3'rin is that the latter is simply haematin free from iron. It
has been found iu the urine in pulmonary tuberculosis, pleurisy with effusion,
UREMIA. 683
acute rlieumatisni, lead poisoning, and intestinal haemorrhages. This pig-
ment has been found very frequently after the administration of sulphonal,
and sometimes imparts a very dark color to the urine.
V. UREMIA.
Definition. — A toxemia developing in the course of nephritis or in con-
ditions associated with anuria. The nature of the poison or poisons is as yet
unknown, whether they are the retained normal products or the products of
an abnormal metabolism.
Theories of TJrsemia. — The view most widely held is that uraemia is due to
the accumulation in the blood of excrementitious material — body poisons —
which should be thrown off by the kidneys. " If, however, from any cause,
these organs make default, or if there be any prolonged obstruction to the
outflow of urine, accumulation of some or of all the poisons takes place, and
the characteristic s3anptoms are manifested, but the accumulation may be very
slow and the earlier symptoms, corresponding to the comparatively small
dose of poison, may be very slight ; yet they are in kind, though not in degree,
as indicative of uraemia as are the more alarming, which appear toward the
end, and to which alone the name ursemia is often given" (Carter). Herter
and others have shown that the toxicity of the blood-serum in uraemic states is
increased. The part played by urea itself, by the salts, and by the nitrogenous
extractives has not been determined.
Another view is that uraemia depends on the products of an abnormal
metabolism. Brown-Sequard suggested that the kidney has an internal secre-
tion, and it is urged that the symptoms of uraemia are due to its disturbance.
Bradford's experiments show that the kidneys do influence profoundly the
metabolism of the tissues of the body, particularly of the muscles. If more than
two-thirds of the total kidney weight be removed, there is an extraordinary
increase in the production of urea and of the nitrogenous bodies of the creatin
class. He favors this view, but acknowledges that we are still ignorant of the
nature of the poison. From a careful study of the question, Hughes and
Carter concluded that the poison was an albuminous product quite different
from anything in normal urine. In Bradford's Goulstonian Lectures (1898)
will be found a full discussion of the question.
Traube believed that the symptoms of uraemia, particularly the coma and
convulsions, were due to localized oedema of the brain.
Symptoms. — Clinically, we may recognize latent, acute, and chronic forms
of uraemia. The latent form has been considered under the section on anuria.
Acute uraemia may arise in any form of nephritis. It is more common in
the post-febrile varieties. Bradford thinks that it 'is specially associated with
a form of contracted white kidney in young subjects. Chronic forms of
uraemia are more frequent in the arterio-sclerotic and granular kidney. For
convenience the symptoms of uraemia may be described under cerebral, dysp-
nceic, and gastro-intestinal manifestations.
Among the Cerebeal s}Tnptoms of ursemia may be described :
(a) Mania. — This may come on abruptly in an individual who has shown
no previous indications of mental trouble, and who may not be known to
have Bright's disease. In a remarkable case of this kind which came under
684 DISEASES OF THE KIDNEYS.
my observation the patient l^ecame suddenly maniacal and died in six days.
More commonly the delirium is less violent, but the patient is noisy, talka-
tive, restless, and sleepless.
(h) Delusional Insanity (FoUe Briglitique). — Cases are by no means un-
common, and excellent clinical reports have been issued on the subject from
several of the asylums, particularly by Bremer, Christian, and Alice Bennett.
Delusions of persecution are common. One of my cases committed suicide by
jumping out of a window. The condition is of interest medico-legally because
of its bearing on testamentary capacity. Profound melancholia may also
supervene.
(c) Convulsions. — These may come on unexpectedly or be preceded by
pain in the head and restlessness. The attacks may be general and identical
with those of ordinary epilepsy, though the initial cry may not be present.
The fits may recur rapidly, and in the interval the patient is usually uncon-
scious. Sometimes the temperature is elevated, but more frequently it is de-
pressed, and may sink rapidly after the attack. Local or Jacksonian epilepsy
may occur in most characteristic form in uremia. A remarkable sequence of
the convulsions is blindness — urcemic amaurosis — which may persist for sev-
eral days. This, however, may occur apart from the convulsions. It usually
passes off in a day or two. There are, as a rule, no ophthalmoscopic changes.
Sometimes ura3mic deafness supervenes, and is probably also a cerebral mani-
festation. It may also occur in connection with persistent headache, nausea,
and other gastric symptoms.
{d) Coma. — ^Unconsciousness invariably accompanies the general convul-
sions, but a coma may develop gradually -without any convulsive seizures. Fre-
quently it is preceded by headache, and the patient gradually becomes dull
and apathetic. In these cases there may have been no previous indications of
renal disease, and unless the urine is examined the nature of the case may be
overlooked. Twitchings of the muscles occur, particularly in the face and
hands, but there are many cases of coma in which the muscles are not involved.
In some of these cases a condition of torpor persists for weeks or even months.
The tongue is usually furred and the breath very foul and heavy.
(e) Local Palsies. — In the course of chronic Bright's disease hemiplegia
or monoplegia may come on spontaneously or follow a convulsion, and post
mortem no gross lesions of the brain be found, but only a localized or diffused
oedema. These cases, which are not very uncommon, may simulate almost every
form of organic paralysis of cerebral origin.
(/) Of other cerebral symptoms, headache is important. It is most
often occipital and extends to the neck. It may be an early feature and asso-
ciated with giddiness. Other nervous symptoms of uremia are intense itching
of the skin, numbness and tingling in the fingers, and cramps in the muscles
of the calves, particularly at night. An erythema may be present.
IjEiEiiic DTSPNCEA is classified by Palmer Howard as follows: (1) Con-
tinuous dj^spncea; (2) paroxysmal dyspncea; (3) both types alternating; and
(4) Cheyne- Stokes breathing. The attacks of dyspnoea are most commonly
nocturnal; the patient may sit up, gasp for breath, and evince as much dis-
tress as in true asthma. Occasionally the breathing is noisy and stridulous.
The Chejme-Stokes type may persist for weeks, and is not necessarily associated
with coma. I have seen it in a man who travelled over a hundred miles to
UREMIA. 685
consult a physician. In another instance a patient, up and about, could when
at meals feed himself only in the apnoea period. Though usually of serious
omen and occurring with coma and other symptoms, recovery may follow
even after persistence for weeks or even months.
The GASTEO-iNTESTiNAL manifestations of uremia often set in with abrupt-
ness. Uncontrollable vomiting may come on and its cause be quite unrecog-
nizable. A young married woman was admitted to my wards in the Montreal
General Hospital with persistent vomiting of four or five days' duration.
The urine was slightly albuminous, but she had none of the usual signs of
ursmia, and the case was not regarded as one of Bright's disease. The vom-
iting persisted and caused death. The post mortem showed extensive sclero-
sis of both kidneys. The attacks may be preceded by nausea and may be asso-
ciated with diarrhoea. In some instances the diarrhoea may come on without
the vomiting ; sometimes it is profuse and associated with an intense catarrhal
or even diphtheritic inflammation of the colon.
A special uremic stomatitis has been described (Barie) in which the
mucosa of the lips, gums, and tongue is swollen and erythematous. The saliva
may be increased, and there is difficulty in swallowing and in mastication.
The tongue is usually very foul and the breath heavy and fetid. A cutaneous
erythema may occur and a remarkable urea " frost " on the skin.
Fever is not uncommon in urgemic states, and may occur with the acute
nephritis, with the complications, and as a manifestation of the uremia itself
(Stengel).
Very many patients with chronic uraemia succumb to what I have called
terminal infections — acute peritonitis, pericarditis, pleurisy, meningitis, or
endocarditis.
Diagnosis. — Herter calls attention to the value of the clinical determina-
tion of the urea in the blood (for which purpose only a few cubic centimetres
are required) as an index of the degree of renal inadequacy. Cryoscopy, the
electrical conductivity of blood and urine, also the methylene blue, potassium
iodide, salicylic-acid tests have been employed in the hope of testing the func-
tional ability of the kidneys. The result has been that while in some cases
of urgemia one finds the expected accumulation of urea and ions in the
blood, in others the kidneys are, judged by these tests, normal. In some
cases of nephritis without any signs of ursemia the kidneys are apparently
as insufficient as the worst uremia cases. In but 2 of 96 cases could the urea
determination have been of any value in predicting ursemia, and equal drops
in the urea occurred without this symptom (Emerson).
It is still common to depend on the urea estimation as of service in fore-
telling an ursemia, but in the 96 cases of nephritis with ursemia in my wards
in but 2 cases was it of any real value.
Ursemia may be confounded with :
(a) Cerebral lesions, such as hsemorrhage, meningitis, or even tumor. In
apoplexy, which is so commonly associated with kidney disease and stiff arte-
ries, the sudden loss of consciousness, particularly if with convulsions, may
simulate a ursemic attack; but the mode of onset, the existence of complete
hemiplegia, with conjugate deviation of the eyes, suggest haemorrhage. As
already noted, there are cases of uremic hemiplegia or monoplegia which can
not be separated from those of organic lesion and which post mortem show
686 DISEASES OF THE KIDNEYS.
no trace of coarse disease of the brain. I know of an instance in wMcli a con-
sultation was held upon the propriet}^ of operation in a case of hemiplegia
believed to be due to subdural haemorrhage which post mortem was shown to
be urtemic. Indeed, in some of these cases it is quite impossible to distinguish
between the two conditions. So, too, cases of meningitis, in a condition of
deep coma, with perhaps slight fever, furred tongue, but without localizing
s}Tnptoms, may readily be confounded with urtemia.
(&) With certain infectious diseases. ITrEemia may persist for weeks or
months and the patient lies in a condition of torpor or even unconsciousness,
with a heavily coated, perhaps dry, tongue, muscular twitchings, a rapid feeble
pulse, with slight fever. This state not unnaturally suggests the existence of
one of the infectious diseases. Cases of the kind are not uncommon, and I
have known them to be mistaken for t}iDhoid fever and for miliary tuberculosis.
(c) IJraemic coma may be confounded with poisoning by alcohol or opium.
In opium poisoning the pupils are contracted; in alcoholism they are more
commonly dilated. In uremia they are not constant; they may be either
vridelv dilated or of medium size. The examination of the eye-ground should
be made to determine the presence or absence of albuminuric retinitis. The
urine should be dra^m off and examined. The odor of the breath sometimes
gives an important hint.
The condition of the heart and arteries should also be taken into account.
Sudden uraemic coma is more common in the chronic interstitial nephritis.
The character of the delirium in alcoholism is sometimes important,' and the
coma is not so deep as in uraemia or opium poisoning. It may for a time be
impossible to determine whether the condition is due to ursemia, profound
alcoholism, or haemorrhage into the pons Varolii.
And lastly, in connection with sudden coma, it is to be remembered that
insensilDility may occur after prolonged muscular exertion, as after running
a ten-mile race. In some instances unconsciousness Has come on rapidly with
stertorous breathing and dilated pupils. Cases have occurred under conditions
in which sun-stroke could be excluded; and Poore, who reports a case in the
Lancet (1894), considers that the condition is due to the too rapid accumu-
lation of waste products in the blood, and to hyperpjTCxia from suspension of
sweating.
The treatment will be considered under Chronic Bright's Disease.
VI. ACUTE BRIGHT 'S DISEASE.
Definition. — Acute diffuse nephritis, due to the action of cold or of toxic
agents upon the kidneys.
In all instances changes exist in the epithelial, vascular, and intertubular
tissues, which vary in intensity in different forms; hence writers have de-
scribed a tubular, a glomerular, and an acute interstitial nephritis. Delafield
recognizes acute exudative and acute productive forms, the latter characterized
by proliferation of the connective-tissue stroma and of the cells of the Mal-
pighian tufts.
Etiology. — The following are the principal causes of acute nephritis:
(1) Cold. Exposure to cold and wet is one of the most common causes.
It is particularly prone to follow exposure after a drinking-bout.
ACUTE BRIGHT'S DISEASE. 687
(2) The poisons of the specific fevers, particularly scarlet fever, less com-
monly typhoid fever, measles, diphtheria, small-pox, chicken-pox, malaria,
cholera, yellow fever, meningitis, and, very rarely, dysentery. Acute nephritis
may be associated with syphilis and with acute tuberculosis, particularly the
former, to which Bradford has recently called attention as an important cause.
He suggests that many of the idiopathic cases and those ascribed to cold may
be of syphilitic origin. It may also occur in septicaemia and in acute ton-
sillitis. In exudative erythema and the allied purpuric affections acute
nephritis is not uncommon. Among 1,833 cases of malaria at the Jolins
Hopkins Hospital there were 26 of nephritis (Thayer),
(3) Toxic agents, such as turpentine, cantharides, potassium chlorate,
and carbolic acid may cause an acute congestion which sometimes terminates
in nephritis. Alcohol probably never excites an acute nephritis.
(4) Pregnancy, in which the condition is thought by some to result from
compression of the renal veins, although this is not yet finally settled. The
condition may in reality be due to toxic products as yet undetermined.
(5) Acute nephritis occurs occasionally in connection with extensive lesions
of the skin, as in burns or in chronic skin-diseases, and also after trauma. It
may follow operations on the kidney.
Morbid Anatomy. — The kidneys may present to the naked eye in mild
eases no evident alterations. When seen early in more severe forms the organs
are congested, swollen, dark, and on section may drip blood. Bright's original
description is as follows :
" The kidneys . . . stripped easily out of their investing membrane,
were large and less firm than they often are, of the darkest chocolate color,
interspersed with a few white points, and a great number nearly black; and
this, with a little tinge of red in parts, gave the appearance of a polished fine-
grained porphyry or greenstone. . . . On (section) these colors were found
to pervade the whole cortical part; but the natural striated appearance was
not lost, and the external part of each mass of tubuli was particularly dark
. . . a very considerable quantity of blood oozed from the kidney, showing
a most unusual accumulation in the organ."
In other instances the surface is pale and mottled, the capsule strips off
readily, and the cortex is swollen, turbid, and of a grayish-red color, while
the pyramids have an intense beefy-red tint. The glomeruli in some instances
stand out plainly, being deeply swollen and congested ; in other instances they
are pale.
Histology. — The histology may be thus summarized: (a) Glomerular
changes. In a majority of thei cases of nephritis due to toxic agents, which
reach the kidney through the blood-vessels, the tufts suffer first, and there is
either an acute intracapillary glomerulitis, in which the capillaries become
filled with cells and thrombi, or involvement of the epithelium of the tuft and
of Bo-wman's capsule, the cavity of which contains leucocytes and red blood-
corpuscles. Hyaline degeneration of the contents and of the walls of the
capillaries of the tuft is an extremely common event. These processes are
perhaps best marked in scarlatinal nephritis. There may be proliferation
about Bowman's capsule. These changes interfere with the circulation in the
tufts and seriously influence the nutrition of the tubular structures beyond
them.
688 DISEASES OF THE KIDNEYS.
(h) The alterations in the tubular epithelium consist in cloudy swelling,
fatty change, and hyaline degeneration. In the convoluted tubules, the
accumulation of altered cells with leucocytes and blood-corpuscles causes the
enlargement and swelling of the organ. The epithelial cells lose their
striation, the nuclei are obscured, and hyaline droplets often accumulate in
them.
(c) Interstitial changes. In the milder fotms a simple inflammatory
exudate — serum mixed with leucocytes and red blood-corpuscles — exists be-
tween the tubules. In severer cases areas of small-celled infiltration occur
about the capsules and between the convoluted tubes. These changes may
be wide-spread and uniform throughout the organs or more intense in certain
regions.
Councilman has described an acute interstitial nephritis occurring chiefly
in children after fevers, characterized by the presence of cells similar to those
described by Unna as plasma cells. He thinks that these cells are formed in
other organs, chiefly the spleen and bone marrow, and are carried to the
kidneys in the blood-current.
Symptoms. — The onset is usually sudden, and when the nephritis follows
cold, dropsy may be noticed within twenty-four hours. After fevers the onset
is less abrupt, but the patient gradually becomes pale and a puffiness of the
face or swelling of the ankles is first noticed. In children there may at the
outset be convulsions. Chilliness or rigors initiate the attack in a limited
number of cases. Pain in the back, nausea, and vomiting may be present.
The fever is variable. Many cases in adults have no rise in temperature. In
young children with nephritis from cold or scarlet fever the temperature may,
for a few days, range from 101° to 103°.
The most characteristic symptoms are the urinary changes. There may
at first be suppression; more commonly the urine is scanty, highly colored,
and contains blood, albumin, and tube-casts. The quantity is reduced and
only 4 or 5 ounces may be passed in the twenty-four hours ; the specific grav-
ity is high — 1.025, or even more; the color varies from a smoky to a deep
porter color, but is seldom bright red. On standing there is a heavy deposit ;
microscopically there are blood-corpuscles, epithelium from the urinary pas-
sages, and hyaline, blood, and epithelial tube-casts. The albumin is abundant,
forming a curdy, thick precipitate. The largest amounts of albumin are seen
in the early acute nephritis of syphilis. In Hoffmann's case this reached 8.5
per cent. The total excretion of urea is reduced, though the percentage is
high.
Ancemia is an early and marked symptom. In cases of extensive dropsy,
effusion may take place into the pleura and peritonaeum. There are cases
of scarlatinal nephritis in which the dropsy of the extremities is trivial and
effusion into the pleurae extensive. The lungs may become oedematous. In
rare cases there is oedema of the glottis. Epistaxis may occur or cutaneous
ecchymoses may develop in the course of the disease.
The pulse may be hard, the tension increased, and the second sound in
the aortic area accentuated. Occasionally dilatation of the heart comes on
rapidly and may cause sudden death (Goodhart). The skin is dry and it may
be difficult to induce sweating.
Urcemic sjrmptoms occur in a limited number of cases, either at the onset
ACUTE BRIGHT' S DISEASE. 689
with suppression, more commonly later in the disease. Ocular changes are
not so common in acute as in chronic Bright's disease, but hsemorrhagic
retinitis may occur and occasionally papillitis.
The course of acute Bright's disease varies considerably. The description
just given is of the form which most commonly follows cold or scarlet fever.
In many of the febrile cases dropsy is not a prominent symptom, and the
diagnosis rests rather with the examination of the urine. Moreover, the con-
dition may be transient and less serious. In other cases, as in the acute
nephritis of typhoid fever, there may be hsematuria and pronounced signs of
interference with the renal function. The most intense acute nephritis may
exist without anasarca.
In scarlatinal nephritis, in which the glomeruli are most seriously affected,
suppression of the urine may be an early symptom, the dropsy is apt to be
extreme, and ursemic manifestations are common. Acute Bright's disease in
children, however, may set in very insidiously and be associated with transient
or slight oedema, and the symptoms may point rather to affection of the
digestive system or to brain-disease.
Diagnosis. — It is very important to bear in mind that the most serious
involvement of the kidneys may be manifested only by slight cedema of the
feet or puffiness of the eyelids, without impairment of the general health. On
the other hand from the urine alone a diagnosis can not be made with cer-
tainty since simple cloudy, swelling, and circulatory changes may cause a simi-
lar condition of urine. The first indication of trouble may be a ursemic con-
vulsion. This is particularly the case in the acute nephritis of pregnancy, and
it is a good rule for the practitioner, when engaged to attend a case, invariably
to ask that during the seventh and eighth months the urine should occasionally
be sent for examination.
In nephritis from cold and in scarlet fever the symptoms are usually
marked and the diagnosis is rarely in doubt. As already mentioned, every
case in which albumin is present must not be called acute Bright's disease,
not even if tube-casts be present. Thus the common febrile albuminuria,
although it represents the first link in the chain of events leading to acute
Bright's disease, should not be placed in the same category.
There are occasional cases of acute Bright's disease with anasarca, in
which albumin is either absent or present only as a trace. This is a rare
condition. Tube-casts are usually found, and the absence of albumin is rarely
permanent. The urine may be reduced in amount.
The character of the casts is of use in the diagnosis of the form of
Bright's disease, but scarcely of such extreme value as has been stated. Thus,
the hyaline and granular casts are common to all varieties. The blood and
epithelial casts, particularly those made up of leucocytes, are most common
in the acute cases.
Prognosis. — The outlook varies somewhat with the cause of the disease.
Eecoveries in the form following exposure to cold are much more frequent
than after scarlatinal nephritis. In younger children the mortality is high,
amounting to at least one-third of the cases. Serious symptoms are low
arterial tension, the occurrence of uraemia, and effusion into the serous sacs.
The persistence of the dropsy after the first month, intense pallor, and a large
amount of albumin indicate the possibility of the disease becoming chronic.
45
690 DISEASES OF THE KIDNEYS.
For some months after the disappearance of the dropsy there may be traces
of albumin and a few tube-casts.
In a case of scarlatinal nephritis, if the progress is favorable, the dropsy
diminishes in a week or ten days, the urine increases, the albumin lessens,
and by the end of a month the dropsy has disappeared and the urine is nearly
free. In very young children the course may be rapid, and I have known the
urine to be free from albumin in the fourth week. Other cases are more
insidious, and though the dropsy may disappear, the albumin persists in the
urine, the angemia is marked, and the cojidition becomes chronic, or, after
several recurrences of the dropsy, improves and complete recovery takes place.
Treatment. — The patient should be in bed and there remain until all
traces of the disease have disappeared. As sweating plays such an important
part in the treatment, it is well, if possible, to accustom the patient to
blankets. He should also be clad in thin Canton flannel.
The diet should consist of milk or butter-milk, gruels made of arrow-root
or oat-meal, barley water, and, if necessary, beef tea and chicken broth. It is
better, if possible, to confine the patient to a strictly milk diet. As conva-
lescence is established, bread and butter, lettuce, water-cress, grapes, oranges,
and other fruits may be given. Meats should be used very sparingly. As
there is marked retention of the chlorides, which seem to bear a relation to the
dropsy, salt should be withheld.
The patient should drink freely of alkaline mineral waters, ordinary water,
or lemonade. The fluids keep the kidneys flushed and wash out the dehris
from the tubes. A useful drink is a drachm of cream of tartar in a pint of
boiling water, to which may be added the juice of half a lemon and a little
sugar. Taken when cold, this is a pleasant and satisfactory diluent drink.
ISTo remedies, so far as known, control directly the changes which are going
on in the kidneys. The indications are : (1) To give the excretory function of
the kidney rest by utilizing the skin and the bowels, in the hope that the
natural processes may be sufficient to effect a cure; (2) to meet the symptoms
as they arise.
In a case of scarlet fever it may occasionally be possible to avert an attack,
the premonitory symptoms of which are marked increase in the arterial tension
and the presence of blood coloring matter in the urine (Mahomed), An
active saline cathartic may completely relieve this condition.
At the onset, when there is pain in the back or hsematuria, the Paquelin
cautery or the dry or wet cups give relief. The last should not be used in
children. Warm poultices are often grateful. In cases which set in with
suppression of urine, these measures should be adopted, and in addition the
hot bath with subsequent pack, copious diluents, and a free purge. The dropsy
is best treated by hydrotherapy — either the hot bath, the wet pack, or the
hot-air bath. In children the wet pack is usually satisfactory. It is applied
by wi'inging a blanket out of hot water, wrapping the child in it, covering this
with a dry blanket, and then with a rubber cloth. In this the child may
remain for an hour. It may be repeated daily. In the case of adults, the
hot-air bath or the vapor bath may be conveniently given by allowing the
vapor or air to pass from a funnel beneath the bed-clothes, which are raised
on a low cradle. More efficient, as a rule, is a hot bath of from fifteen or
twenty minutes, after which the patient is wrapped in blankets. The sweating
ACUTE BRIGHT'S DISEASE. 691
produced by these measures is usually profuse, rarely exhausting, and in a
majority of cases the dropsy can in this way be relieved. There are some
cases, however, in which the skin does not respond to the baths, and if the
symptoms are serious, particularly if uraemia supervenes, jaborandi or its
active principle, pilocarpine, may be used. The latter may be given hypoder-
micall}^, in doses of from a sixth to an eighth of a grain in adults, and from a
twentieth to a twelfth of a grain in children of from two to ten years.
The bowels should be kept open by a morning saline purge ; in children the
fluid magnesia is readily taken; in adults the sulphate of magnesia may be
given by Hay's method, in concentrated form, in the morning, before anything
is taken into the stomach. In Bright's disease it not infrequently causes
vomiting. The compound powder of jalap, in half -drachm doses, or, if neces-
sary, elaterium may be used. If the dropsy is not extreme, the urine not very
concentrated, and urgemic symptoms are not present, the bowels should be kept
loose without active purgation. If these measures fail to reduce the dropsy and
it has become extreme, the skin may be punctured with a lancet or drained
by a small silver canula (Southey's tube), which is inserted beneath it. A
fine aspirator needle may be used, and the fluid allowed to drain through a
piece of long, narrow rubber tubing into a vessel beneath the bed. If the
dyspnoea is marked, owing to pressure of fluid in the pleurae, aspiration should
be performed. In rare instances the ascites is extreme and may require para-
centesis, or a Southey's tube may be inserted and the fluid gradually withdrawn.
If ursemic convulsions occur, the intensity of the paroxysms may be limited
by the use of chloroform; to an adult a pilocarpine injection should be at
once given, and from a robust, strong man 20 ounces of blood may be with-
drawn. In children the loins may be dry cupped, the wet pack used, and a
brisk purgative given. Bromide of potassium and chloral sometimes prove
useful.
Vomiting may be relieved by ice and by restricting the amount of food.
Drop doses of creasote, iodine, and carbolic acid may be given. The dilute
hydrocyanic acid with bismuth is often effectual.
The question of the use of diuretics in acute Bright's disease is not yet
settled. The best diuretic, after all, is water, which may be taken freely
with the citrate of potash or the benzoate of soda, salts which are held to favor
the conversion of the urates into less irritating and more easily excreted com-
pounds. Digitalis and strophanthus are useful diuretics, and may be employed
without risk when the arterial tension is low and the cardiac impulse is not
forcible. * I have never seen any injurious effects from their employment after
the early symptoms had lessened in intensity.
For the persistent albuminuria, I agree with Eoberts and Eosenstein that
we have no remedy of the slightest value. Kothing indicates more clearly our
helplessness in controlling kidney metabolism than inability to meet this com-
mon symptom. Astringents, alkalies, nitroglycerin, and mercury have been
recommended.
For the anaemia always associated with acute Bright's disease iron should
be employed. It should not be given until the acute symptoms have subsided.
In the adult it may be used in the form of the perchloride in increasing doses,
as convalescence proceeds. In children, the syrup of the iodide of iron or the
syrup of the phosphate of iron are better preparations. Tyson has recently
692 DISEASES OF THE KIDNEYS.
urged caution in the too free use of iron in kidney disease. The dilatation of
the heart is best treated with digitalis, strophanthus, and strychnia.
In the convalescence from acute Bright's disease, cart should be taken to
guard the patient against cold. The diet should still consist chiefly of milk
and a return to mixed food should be gradual. A change of air is often bene-
ficial, particularly a residence in a warm, equable climate.
Vn. CHRONIC BRIGHT'S DISEASE.
Here, too, in all forms we deal with a diffuse process, involving epithelial,
interstitial, and glomerular tissues. Clinically two groups are recognized —
(a) the chronic parenchymatous nephritis, which follows the acute attack or
comes on insidiously, is characterized by marked dropsy, and post mortem by
the large white Tiidney. In the later stages of this process the kidney may be
smaller — a condition known as the small white Jcidney; (h) chronic inter-
stitial nephritis, in which dropsy is not common and the cardio-vascular
changes are pronounced. Delafield recognizes a chronic diffuse nephritis with
exudation and a chronic jDroductive diffuse nephritis without exudation, the
latter corresponding to the contracted kidney of authors.
The amyloid kidney is usually spoken of as a variety of Bright's disease,
but in reality it is a degeneration wliich may accompany any form of nephritis.
1. Cheoxic Paeexchtmatous Nepheitis
(Chrotiic Desquamative and Chronic Tubal NepTiritis; Chronic Diffuse
Nephritis with Exudation) .
Etiology. — In many cases the disease follows the acute nephritis of cold,
scarlet fever, or pregnancy. More frequently than is usually stated the disease
has an insidious onset and occurs independently of any acute attack. The
fevers may play an important I'ole in certain of these cases. Eosenstein, Bar-
tels, and, in this country, I. E. Atkinson and Thayer have laid special stress
upon malaria as a cause. The use of alcohol is believed to lead to this form of
nephritis. In chronic suppuration, syphilis, and tuberculosis the diffuse paren-
ch}Tnatous nephritis is not uncommon, and is usualty associated with amyloid
disease. Males are rather more subject to the affection than females. It is
met with most commonly in young adults, and is by no means infrequent in
children as a sequence of scarlatinal nephritis.
Morbid Anatomy. — Several varieties of this form have been recognized.
The large white ]cid?iey of Wilks, in which the organ is enlarged, the capsule
is thin, and the surface white with the stellate veins injected is not very com-
mon in America. On section the cortex is swollen and yellowish- white in color,
and often presents opaque areas. The p}Tamids may be deeply congested. On
microscopical examination it is seen that the epithelium is granular and fatty,
and the tubules of the cortex are distended, and contain tube-casts. Hyaline
changes are also present in the epithelial cells. The glomeruli are large, the
capsules thickened, the capillaries show hyaline changes, and the epithelium
of the tuft and of the capsule is extensively altered. The interstitial tissue is
everywhere increased^ though not to an extreme degree. I have had in my
CHRONIC BRIGHT'S DISEASE. 693
wards but 30 such cases with autopsy. The average weight of both kidneys was
430 grammes, the heaviest 580 grammes.
The second variety of this form results from the gradual increase in the
connective tissue and the subsequent shrinkage, forming what is called the
small white kidney or the pale granular kidney. It is doubtful whether this
is always preceded by the large white kidney. Some observers hold that it may
be a primary independent form. The capsule is thickened and the surface is
rough and granular. On section the resistance is greatly increased, the cortex
is reduced and presents numerous opaque white or whitish-yellow foci, con-
sisting of accumulations of fatty epithelium in the convoluted tubules. This
combination of contracted kidney with the areas of marked fatty degeneration
has given the name of small granular fatty kidney to this form. The inter-
stitial changes are marked, many of the glomeruli are destroyed, the degenera-
tion of epithelium in the convoluted tubules is wide-spread, and the arteries
are greatly thickened.
Belonging to this chronic tubal nephritis is a variety known as the chronic
hcemorrhagic nephritis^ in which the organs are enlarged, yellowish-white in
color, and in the cortex are many brownish-red areas, due to haemorrhage into
and about the tubes. In other respects the changes are identical with those in
the large white kidney.
Of changes in the other organs the most marked are thickening of the
blood-vessels and hypertrophy of the left heart.
Symptoms. — Following an acute nephritis, the disease may present, in a
modified way, the symptoms of that affection. In many cases it sets in
insidiously, and after an attack of dyspepsia or a period of failing health and
loss of strength the patient becomes pale, and pufifiness of the eyelids or swollen
feet are noticed in the morning.
The symptoms are as follows : The urine is, as a rule, diminished in quan-
tity, averaging 500 cc, often scanty. It has a dirty-yellow, sometimes smoky,
color, and is turbid from the presence of urates. On standing, a heavy sedi-
ment falls, in which are found numerous tube-casts of various forms and sizes,
hyaline, both large and small, epithelial, granular, and fatty casts. Leuco-
cytes are abundant; red blood-corpuscles are frequently met with, and epi-
thelium from the kidneys and pelves. The albumin is abundant and may be
from 4 to 6 per cent. It is more abundant in the urine passed during the day.
The specific gravity may be high in the early stages — from 1.020 to 1.025, even
1.040 — though in the later stages it is lower. The urea is always reduced in
quantity. As the case improves from 5 to 6 litres a day may be voided.
Dropsy is a marked and obstinate symptom of this form of Bright's dis-
ease. The face is pale and puffy, and in the morning the eyelids are oede-
matous. The anasarca is general, and there may be involvement of the serous
sacs. In these chronic cases associated with large white kidney there is often a
distinctive appearance in the face ; the complexion is pasty, the pallor marked,
and the eyelids are oedematous. The dropsy is peculiarly obstinate. Urgemic
symptoms are common, though convulsions are perhaps less frequent than in
the interstitial nephritis.
The tension of the pulse is usually increased ; the vessels ultimately become
stiff and the heart hypertrophied, though there are instances of this form of
nephritis in which the heart is not enlarged. The aortic second sound is
694 DISEASES OF THE KIDNEYS.
accentuated. Eetinal changes, though less frequent than in the chronic inter-
stitial neiDliritis, occur in a considerable number of cases.
Gastro-intestinal symptoras are common. Vomiting is frequently* a dis-
tressing and serious sj-mptom, and diarrhcea may be profuse. Ulceration of
the colon may occur and prove fatal.
It is sometimes impossible to determine, even by the most careful exami-
nation of the urine or by analysis of the s}Tnptoms, whether the condition of
the kidney is that of the large white or of the small white form. In cases,
however, which have lasted for several years, with the progressive increase in
the renal connective tissue and the cardio-vascular changes, the clinical picture
may approach, in certain respects, that of the contracted kidney. The urine
is increased, with low specific gravity. It is often turbid, may contain traces
of blood, the tube-casts are numerous and of every variety of form and size,
and the albumin is abundant. Dropsy is usually present, though not so
extensive as in the early stages.
Prognosis. — The prognosis is e-slre^ely grave. In a case which has per-
sisted for more than a year recovery rarely takes place. Death is caused either
by great effusion with oedema of the lungs, by uraemia, or by secondary inflam-
mation of the serous membranes. Occasionally in children, even when the
disease has persisted for two years, the symptoms disappear and recovery takes
place.
Treatment. — Essentially the same treatment should be carried out as in
acute Bright's disease. Milk or butter-milk should constitute for a time the
chief article of food. Later more food may be allowed, oysters, fresh vege-
tables, and fruit. The dropsy should be treated by the hot baths, and a salt-
free diet. Iron preparations should be given when there is marked anaemia.
It is to be remembered that the pallor of the face may not be a good index of
the blood condition. The acetate of potash, digitalis, and diuretin are useful
in increasing the flow of urine. Basham's mixture given in plenty of water
will be found beneficial.
2. Chronic Interstitial ^vTephritis
(Contracted Kidney; Granular Kidney; Cirrliosis of tlie Kidney; Gouty Kid-
ney; Renal Sclerosis).
Sclerosis of the kidney is met with (a) as a sequence of the large white
kidney, forming the so-called pale granular or secondary contracted kidney;
(h) as an independent primary affection; (c) as a sequence of arterio-sclerosis.
Etiology. — The primary form is chronic from the outset, and is a slow,
creeping degeneration of the kidney substance — in many respects only an
anticipation of the gradual changes which take place in the organ in extreme
old age. In man}' cases no satisfactory cause can be assigned. In others there
are hereditary influences, as in the remarkable family studied by Dickinson,
in which a pronounced tendency to chronic Bright's disease occurred in four
generations. Families in which the arteries tend to degenerate early are more
prone to interstitial nephritis. Syphilis is held by some to be a cause, and
possibly in some cases the mercurial treatment. Alcohol probably plays an
important part, particularly in conjunction with other factors. Among the
better classes in America chronic Bright's disease is very common, and is, I
CHRONIC BPdGlirS DISEASE. 695
believe, caused luorc ficqucnlly by o\e:catiiig than by excesses in alcoliol.
Some believe excesoive u^e of meat is injurious, since it increases the mate-
rials out of which uric acid is formed. By many a functional disorder of the
liver, leading to lithsmia, is regarded as the most efficient factor. It is quite
possible that in persons who habitually eat and drink too much the work
thrown upon this organ is excessive, and the elaboration of certain materials
is so defective that in their excretion from the general circulation they irritate
the kidneys. Actual gout, which in England is a common cause of inter-
stitial nephritis, is not an important factor here. Lead, as is well known, may
produce renal sclerosis. For a full discussion on the etiology and varieties of
renal cirrhosis the student is referred to the work of S. West.
Arteriosclerotic Form. — By far the most common form in America is
secondary to arterio-sclerosis. The kidneys are not much, if at all, contracted,
very hard, red, and show patches of cortical atrophy. It is seen in men over
forty who have worked hard, eaten freely, and taken alcohol to excess. They
are conspicuous victims of the " strenuous life," the incessant tension of which
is felt first in the arteries. After forty in men of this class nothing is more
salutary than to experience the shock lirought by the knowledge of the pres-
ence of albumin and tube-casts in the urine. The associated cardio-vascular
changes are of varying degrees of intensity, and upon them, not upon the renal
condition, does the outlook depend.
Morbid Anatomy. — The contracted kidneys are small, and together may
weigh no more than an ounce and a half. Of 174 cases of chronic interstitial
nephritis (white kidney) from my wards, with autopsy, in 79 cases the com-
bined weight of kidneys was over 300 grammes; in 57 cases, 200-300
grammes; 30 cases, 150-200 grammes; and below 150 grammes, 8 cases. Of
the arterio-sclerotic form 61 per cent weighed over 300 grammes and but 6
per cent below 200 grammes. Unilateral nephritis is excessively rare, not
occurring once in the series, a striking contrast to Edebohl's figures, 9 of 72
cases in which the operation of stripping the capsule was performed. The
capsule is thick and adherent; the surface of the organ irregular and cov-
ered with small nodules, which have given to it the name of granular kidney.
In stripping off the capsule, portions of the kidney substance are removed.
Small cysts are frequently seen on the surface. The color is usually reddish,
often a very dark red. On section the substance is tough and resists cutting;
the cortex is thin and may measure no more than a couple of millimetres.
The pyramids are less wasted. The small arteries are greatly thickened and
stand out prominently. The fat about the pelvis is greatly increased. Bright's
original description is as follows :
"... The kidney is quite rough and scabrous to the touch externally,
and is seen to rise in numerous projections not much exceeding a large pin's
head, yellow, red, and purplish. The form of the kidney is often inclined to
be lobulated, the feel is hard, and on making an incision the texture is found
approaching to semi-cartilaginous firmness, giving great resistance to the
knife. The tubular portions are observed to be drawn near to the surface of
the organ, with less interstitial deposit than in the last variety . . . the
kidney . . . (is usually) ... of a purplish gray tinge."
Microscopically there is seen a marked increase in the connective tissue and
degeneration and atrophy of the secreting structures, glomerular and tubal,
696 DISEASES OF THE KIDNEYS.
the former predominating and giving the main characters to the lesion. The
following are the most important changes :
(a) An increase in the fibrous elements, widely distributed throughout the
organ, but more advanced in the cortex, particularly in the tissue between the
medullary rays. In the pjTamids the distribution of new growth is less patchy
and more diffuse. In the early stages of the process there is a small-celled infil-
tration between the tubes and around the glomeruli, and finally this becomes
fibrillated and is seen encircling the tubules and Bowman's capsules, around
the latter often forming concentric layers.
(&) The changes in the glomeruli are striking, and in advanced cases a
very considerable number of them have undergone complete atrophy and are
represented as densely encapsulated hyaline structures. The atrophy is partly
due to changes in the capillary walls and multiplication of cells between the
loops, partly to extensive hyaline degeneration, and in part, no doubt, to the
alterations in the afferent vessels. The normal glomeruli usually show some
thickeiung of the capsule and increase in the cells of the tufts.
(c) The tubules show changes in the epithelium, which vary a good deal
in different localities. Where the connective-tissue growth is most advanced
they are greatly atrophied and the epithelium may be represented by small
cubical cells. In other instances the epithelium has entirely disappeared.
On the other hand, in the regions represented by the projecting granules the
tubules are usually dilated, and the epithelium shows hyaline, fatty, and granu-
lar changes. Very many of them contain dark masses of epithelial debris and
tube-casts. In the interstitial tissue and in the tubules there may be pigment-
ary changes due to hsemorrhage. The dilatation of the tubules may reach an
extreme grade, forming definite cysts.
(d) The arteries show an advanced sclerosis. The intima is greatly thick-
ened and there are changes in the adventitia and in the media, consisting in
increase in the thickness due to proliferation of the connective tissue, in the
latter coat at the expense of the muscular elements.
The view most generally entertained at present is that the essential lesion
is in the secreting tissues of the tubules and the glomeruli, and that the
connective-tissue overgTowth is secondary to this. Greenfield holds that the
primary change is in most instances in the glomeruli, to which both the degen-
eration in the epithelium of the convoluted tubules and the increase in the
intertubular connective tissue are secondary.
Associated with contracted kidney are general arterio-sclerosis and hyper-
trophy of the heart. The changes in the arteries have already been described
in the section on arterio-sclerosis. The hypertrophy of the heart is constant,
and the enlargement may reach an extreme grade. Variations depend, no
doubt, in part upon the extent of the diffuse arterial degeneration, but there
are instances in which the term cor iovinum may be applied to the enlarged
organ. In such cases the h}'pertrophy is not confined to the left ventricle, but
involves the entire heart. The explanation of this has been much discussed.
It was at first held to be due to the increased work thrown upon the organ
in driving the impure blood through the capillary system. Basing his opinion
upon the supposed muscular increase in the smaller arteries, Johnson regarded
it as an effort to overcome a sort of stop-cock action of these vessels, which,
under the influence of the irritating ingredient in the blood, contracted and
CHRONIC bright;^ disease. 697
increased greatly the peripheral resistance. Traube believed that the oblitera-
tion of a large number of capillary territories in the kidney materially raised
the arterial pressure, and in this way led to the hypertrophy of the heart; an
additional factor, he thought, was the diminished excretion of water, which
also heightened the pressure within the blood-vessels.
With our present knowledge the most satisfactory explanation is that given
by Cohnheim, which is thus clearly and succinctly put by Fagge : " He gives
reasons for thinking that the activity of the circulation through the kidneys
at any moment — in other words, the state of the smaller renal arteries as
regards contraction or dilatation — depends not (as in the case of the tissues
generally) upon the need of those organs for blood, but solely upon the amount
of material for the urinary secretion that the circulatory fluid happens then
to contain. This suggestion has bearings . . . upon the development of
hypertrophy in one kidney when the other has been entirely destroyed. But
another consequence deducible from it is that when parts of both kidneys have
undergone atrophy, the blood-ilow to the parts that remain must, cceteris pari-
bus, be as great as it would have been to the whole of the organs if they had
been intact. But in order that such a quantity of blood should pass through the
restricted capillary area now open to it, an excessive pressure must obviously
be necessary. This can be brought to bear only by the exertion of more than
the normal degree of force on the part of the left ventricle, combined with
the maintenance of a corresponding resistance in all other districts of the
arterial system. And so one can account at once for the high arterial pressure
and for the cardio-vascular changes that are secondary to it." W. P. Herring-
ham in a recent study of the subject concludes that the cardiac hypertrophy
depends upon degeneration and rigidity of the aorta and large arteries, changes
which incapacitate them from acting as an elastic reservoir and transfer their
functions to the smaller vessels, which naturally offer much more resistance
and give the heart more work to do.
Symptoms. — Perhaps a majority of the cases are latent, and are not recog-
nized until the occurrence of one of the serious or fatal complications. Even
an advanced grade of contracted kidney may be compatible with great mental
and bodily activity. There may have been no symptoms whatever to suggest
to the patient the existence of a serious malady. In other cases the general
health is disturbed. The patient complains of lassitude, is sleepless, has
to get up at night to micturate; the digestion is disordered, the tongue is
furred; there are complaints of headache, failing vision, and breathlessness
on exertion.
So complex and varied is the clinical picture of chronic Bright's disease
that it will be best to consider the symptoms under the various systems.
Urinary System. — In the small contracted kidney polyuria is common.
Frequently the patient has to get up two or three times during the night to
empty the bladder, and there is increased thirst. It is for these symptoms
occasionally that relief is sought. And yet in many cases with very small
kidneys this feature has not been present. A careful study of the cases from
my wards, of the urine and the anatomical condition, showed that almost
no parallelism could be made between the weight of the kidney, its appear-
ance, and the urine it secreted before death. Of the 174 cases with autopsy, in
almost a third the renal changes were so slight that the nephritis was not men-
698 DISEASES OF THE KIDNEYS.
tioned as a part of the clinical diagnosis (Emerson). The color is a light
3'ellow, and the specific gravity ranges from 1.005 to 1.012. Persistent low
specific gravity is one of the most constant and important features of the
disease. Traces of albumin are found, but may be absent at times, particularly
in the early morning urine. It is often simply a slight cloudiness, and may be
apparent only with the more delicate tests. The sediment is scanty, and in it
a few hyaline or granular casts are found. The quantity of the solid con-
stituents of the urine is, as a rule, diminished, though in some instances the
urea may be excreted in full amount. In attacks of dyspepsia or bronchitis, or
in the later stages when the heart fails, the quantity of albumin may be greatly
increased and the urine diminished. Occasionally blood occurs in the urine,
and there ma}' even be htematuria (S. West). Slight leakage, represented
by the constant presence of a few red cells, may be present early in the disease
and persist for years. In the arteriosclerotic form the quantity of urine is
normal, or reduced rather than increased; the specific gravit}'^ is normal or
high, the color of the urine is good, and there are hyaline and finely granular
casts. The amount of albumin varies greatly with the food and exercise, and
is usually much in excess of that seen with the contracted kidneys, and does
not show so often the albumin-free intervals of that form, also it is more
common to find albumin, no casts, while in the contracted kidney casts, no
albumin, should one be absent.
Circulatory System. — The pulse is hard, the tension increased, and the
vessel wall, as a rule, thickened. As already mentioned, a distinction must
be made between increased tension and thickening of the arterial wall. The
tension may be plus in a normal vessel, but in chronic Bright's disease it is
more common to have increased tension in a stifi: artery.
A pulse of increased tension has the following characters : It is hard and
incompressible, requiring a good deal of force to overcome it; it is persistent,
and in the intervals between the beats the vessel feels full and can be rolled
beneath the finger. These characters may be present in a vessel the walls of
which are little, if at all, increased in thickness. To estimate the latter the
pulse wave should be obliterated in the radial, and the vessel wall felt beyond
it. In a perfecth^ normal vessel the arterial coats, under these circumstances,
can not be differentiated from the surrounding tissue; whereas, if thickened,
the vessel can be rolled beneath the finger. Persistent high blood pressure
is one of the earliest and most important s}Tnptoms of iaterstitial nephritis.
During the disease the pressure may rise to 250 mm. or even 300 mm., but this
is very rare. With dropsy and cardiac dilatation the pressure may fall, but
not necessarily. The cardiac features are equally important, though often
less obvious. H^^pertrophy of the left ventricle occurs to overcome the resist-
ance offered in the arteries. The enlargement of the heart ultimately becomes
more general. The apex is displaced downward and to the left; the impulse
is forcible and may be heaving. In elderly persons with emphysema, the dis-
placement of the apex may not be evident. The first sound at the apex may be
duplicated; more commonly the second sound at the aortic cartilage is accen-
tuated, a ver}'- characteristic sign of increased tension. The sound in extreme
cases may have a bell-like quality. In many cases a systolic murmur develops
at the apex, probably as a result of relative insutficiency. It may be loud and
transmitted to the axilla. Finally the hypertrophy fails, the heart becomes
CHRONIC BRIGHT'S DISEASE. 699
dilated^ gallop rhythm is present, and the general condition is that of a chronic
heart-lesion.
Respiratory System. — Sudden oedema of the glottis may occur. Effu-
sion into the pleurae or sudden oedema of the lungs may prove fatal. Acute
pleuris}^ and pneumonia are not uncommon. Bronchitis is a frequent accom-
paniment, particularly in the winter. Sudden attacks of oppressed breathing,
particularly at night, are not infrequent. This is often a ursemic symptom,
but is sometimes cardiac. The patient may sit up in bed and gasp for breath,
as in true' asthma. Cheyne- Stokes breathing may be present, most commonly
toward the close, but th^^patient may be walking about and even attending to
his occupation.
Digestive System. — Dyspepsia and loss of appetitie are common. Severe
and uncontrollable vomiting may be the first symptom. This is usually re-
garded as a manifestation of ursemia, but it may occur without any other
indications, and I have known it to prove fatal without any suspicion that
chronic Bright's disease was present. Severe and even fatal diarrhoea may
develop. The tongue may be coated and the breath heavy and urinous.
Nervous System. — ^Various cerebral manifestations have already been
mentioned under uraemia. Headache, sometimes of the migraine type, may
be an early and persistent feature of chronic Bright's disease. Cerebral
apoplexy is closely related to interstitial nephritis. The haemorrhage may
take place into the meninges or the cerebrum. It is usually associated with
marked changes in the vessels. Neuralgias, in various regions, are not un-
common.
Special Senses. — Troubles in vision may be the first symptom of the
disease. It is remarkable in how many cases of interstitial nephritis the con-
dition is diagnosed first by the ophthalmic surgeon. The flame-shaped retinal
haemorrhages are the most common. Less frequent is diffuse retinitis or
papillitis. Sudden blindness may supervene without retinal changes —
uraemic amaurosis. Diplopia is a rare event. Recurring conjunctival and
palpebral haemorrhages are fairly common. Auditory troubles are by no
means infrequent in chronic Bright's disease. Ringing in the ears, with
dizziness, is not uncommon. Various forms of deafness may occur. Epis-
taxis is not infrequent, either alone, or of a severe tjrpe in association with
purpura.
Skin. — CEdema is not common in interstitial nephritis. Slight puffiness
of the ankles may be present, but in a majority of the cases dropsy does not
supervene. When extensive, it is almost always the result of gradual failure
of the hypertrophied heart. The skin is often dry and pale, and sweats are not
common. In some instances the sweat may deposit a white frost of urea on
the surface of the skin. Eczema is a common accompaniment of chronic inter-
stitial nephritis. Tingling of the fingers or numbness and pallor — the dead
fingers — are not, as some suppose, in any way peculiar to Bright's disease.
Intolerable itching of the skin may be present, and cramps in the muscles are
by no means rare.
Haemorrhages are not infrequent; epistaxis may prove serious and exten-
sive ; purpura may occur. Broncho-pulmonary hemorrhages are said, by some
French writers, to be common, but no instance of it has come under my obser-
vation. Ascites is rare except in association with cirrhosis of the liver.
700 DISEASES OF THE KIDNEYS.
Diagnosis. — The autopsy often discloses the true nature of the disease,
one of the many intercurrent affections of which may have proved fatal. The
early stages of interstitial nephritis are not recognizable. In a patient with
increased pulse tension (particularly if the vessel wall is sclerotic), with the
apex beat of the heart dislocated to the left, the second aortic sound ringing
and accentuated, the urine abundant and of low specific gravity, with a trace
of albumin and an occasional hyaline or granular cast, the diagnosis of inter-
stitial nephritis may be safely made. Of all the indications, that offered by the
pulse is the most important. Persistent high tension with thickening of the
arterial wall in a man under fifty means that serious mischief has already
taken place, that cardio-vascular changes are certainly, and renal most prob-
ably, present. It is important in the diagnosis of this condition not to rest
content with a single examination of the urine. Both the evening and the
morning secretion should be studied. The sediment should be collected in
a conical glass, and in looking for tube-casts a large surface should be examined
with a tolerably low power and little light. The arterio-sclerotic kidney may
exist for a long time without the occurrence of albumin, or the albumin may
be in very small quantities. Toward the end it is impossible to differentiate
the primary interstitial nephritis from an arterio-sclerotic kidne}^, nor clini-
cally is it of any special value so to do. In middle-aged men, with very high
tension, great thickening of the superficial arteries, and marked hypertrophy
of the heart, the renal are more likely to be secondary to the arterial changes.
Prognosis. — Chronic Bright's disease is an incurable affection, and the
anatomical conditions on which it depends are quite as much beyond the reach
of medicines as wrinkled skin or gray hair. Interstitial nephritis, however,
is compatible with the enjoyment of life for many jeavs, and it is now uni-
versally recognized that increased tension, thickening of the arterial walls, and
polyuria with a small quantity of albumin, neither doom a man to death
within a short time nor necessarily interfere with the pursuits of an active
life so long as proper care be taken. I Imow patients who have had high
tension and a little albumin in the urine with hyaline casts for ten, twelve,
and, in one instance, fifteen years. Serious indications are the occurrence
of ursemic symptoms, dilatation of the heart, the onset of serous effusions, the
onset of Cheyne- Stokes breathing, persistent vomiting, and diarrhoea.
Treatment. — Patients without local indications or in whom the con-
dition has been accidentally discovered should so regulate their lives as to
throw the least possible strain upon heart, arteries, and kidneys. A quiet life
without mental worry, with gentle but not excessive exercise, and residence in
an equable climate, should be recommended. In addition they should be told
to keep the bowels regular, the skin active by a daily tepid bath with friction,
and the urinary secretion free by drinking daily a definite amount of either
distilled water or some pleasant mineral water. Alcohol should be strictly
prohibited. Tea and coffee are allowable.
The diet should be light and nourishing, and the patient should be warned
not to eat excessively, and not to take meat more than once a day. Care in
food and drink is probably the most important element in the treatment of
these early cases.
A patient in good circumstances may be urged to go away during the
winter months, or, if necessary, to move altogether to a warm equable climate,
CHRONIC BRIGHT'S DISEASE. 701
like that of Southern California. There is no doubt of the value in these
cases of removal from the changeable, irregular weather which prevails in the
temperate regions from November until April.
At this period medicines are not required unless for certain special symp-
toms. Patients derive much benefit from an annual visit to certain mineral
springs, such as Poland, Bedford, Saratoga, in this country, and Vichy and
others in Europe. Mineral waters have no curative influence upon chronic
Bright's disease; they simply help the interstitial circulation and keep the
drains flushed. In this early stage, when the patient's condition is good, the
tension not high, and the quantity of albumin small, medicines are not indi-
cated, since no remedies are known to have the slightest influence upon the
progress of the disease. Sooner or later symptoms arise which demand treat-
ment. Of these the following are the most important:
(a) Greatly Increased Arterial Tension. — It is to be remembered that a
certain increase of tension is not only necessary but unavoidable in chronic
Bright's disease, and probably the most serious danger is too great lowering
of the blood tension. The happy medium must be sought between such height-
ened tension as throws a serious strain upon the heart and risks rupture of
the vessels and the low tension which, under these circumstances, is specially
liable to be associated with serous efl^usions. In cases with persistent high
tension the diet should be light, an occasional saline purge should be given,
and sweating promoted by means of hot air or the hot bath. If these meas-
ures do not suffice, nitroglycerin may be tried, beginning with 1 minim of the
1-per-cent solution three times a day, and gradually increasing the dose if
necessary. Patients vary so much in susceptibilty to this drug that in each
case it must be tested, the limit of dosage being that at which the patient
experiences the physiological effect. As much as 10 minims of the 1 -per-
cent solution may be given three times a day. In many cases I have given it
in much larger doses for weeks at a time. I have never seen any ill effects
from it. If the dose is excessive the patients complain at once of flushing or
headache. Its use may be kept up for six or seven weeks, then stopped for a
week and resumed. Its value is seen not only in the reduction of the tension,
but also in the striking manner in Avhich it relieves the headache, dizziness,
and dyspnoea. The sodium nitrite may be given in doses of grs. iii-v three
times a day.
(&) More or less ancemia is present in advanced cases, and is best met
by the use of iron. Weir Mitchell, who has had a unique experience in certain
forms of chronic Bright's disease, gives the tincture of the perchloride of iron
in large doses — from half a drachm to a drachm three times a day. He
thinks that it not only benefits the angemia, but that it also is an important
means of reducing the arterial tension.
(c) Many patients with Bright's disease present themselves for treat-
ment with signs of cardiac dilatation; there is a gallop rhythm or the heart-
sounds have a fcetal character, the breath is short, the urine scanty and highly
albuminous, and there are signs of local dropsy. In these cases the treatment
must be directed to the heart. A morning dose of salts or calomel may be
given, and digitalis in 10-minim doses, three or four times a day. Strychnia
may be used with benefit in this condition. In some instances other cardiac
tonics may be necessary, but as a rule the digitalis acts promptly and well.
702 DISEASES OF THE KIDNEYS.
(d) Urcemic Symptoms. — Even before marked manifestations are present
there may he extreme restlessness, mental wandering, a heavy, foul breath,
and a coated tongue. Headache is not often complained of, though intense
frontal headache may be an early s}Taptom of uremia. In this condition,
too, the patient may complain of palpitation, feelings of numbness, and
sometimes nocturnal cramps. For these symptoms the saline purgatives should
be ordered, and hot baths, so as to induce copious sweating. Grandin states
that irrigation of the bowel with water at a temperature from 120° to 150°
is most useful. Xitroglycerin also may be freely used to reduce the tension.
For the ursmic convulsions, if severe, inhalations of cliloroform may be
used. If the patient is robust and full-blooded, from 12 to 20 oimces of blood
should be removed. The patient should be freely sweated, and if the convul-
sions tend to recur chloral may be given, either by the mouth or per rectum,
or, better still, morphia. Ursemic coma must be treated by active purgation,
and sweating should be promoted by the use of pilocarpine or the hot bath.
For the restlessness and delirium morphia is indispensable. Since its recom-
mendation in urgemic states some years ago, by Stephen MacKenzie, I have
used this remedy extensively- and can speak of its great value in these cases.
I have never seen ill effects or any tendency to coma follow. It is of special
value in the dyspnoea and Che}Tie-Stokes breathing of advanced arterio-scle-
rosis with chronic urgemia.
SuKGiCAL Teeat:mext. — Edebohls has introduced the operation of decap-
sulization of the kidneys in Brighfs disease in order to establish new vascular
connections, and so influence the nutrition and work of the organs. In his
work (Surgical Treatment of Bright's Disease, 1904) records are given of 72
cases; 7 died within two weeks, 22 died at periods more or less remote, 3 disap-
peared from observation, and -40 were known to be living — one eleven years and
eight months after the operation. As Edebohls says, the difficult thing fo
determine is the existence of chronic Bright's disease before operation. Xo
case should be regarded as such on the urine examination alone. The cardio-
vascular condition should be studied and the retinae. There is probably a
small group of suitable cases — the subacute and chronic forms which fol-
low the acute infections — in which the outlook is hopeless from medical treat-
ment.
VIII. AMYLOID DISEASE.
Amyloid (lardaceous or wax}-) degeneration of the kidneys is simply an
event in the process of chronic Bright's disease, most commonly in the chronic
parenchymatous nephritis following fevers, or of cachectic states. It has no
claim to be regarded as one of the varieties of Bright's disease. The affection
of the kidneys is generally a part of a wide-spread amyloid degeneration occur-
ring in prolonged suppuration, as in disease of the bone, in s}^hilis, tubercu-
losis, and occasionally leukaemia, lead poisoning, and gout. It varies curiously
in frequency in different localities.
Anatomically the amyloid kidne}' is large and pale, the surface smooth,
and the vense stellatae well marked. On section the cortex is large and may
show a peculiar glistening, infiltrated appearance, and the glomeruli are very
distinct. The p}Tamids, in striking contrast to the cortex, are of a deep red
color. A section soaked in dilute tincture of iodine shows spots of a walnut
PYELITIS. 703
or mahogany brown color. The Malpighian tufts and the straight vessels may-
be most affected. In lardaceous disease of the kidneys the organs are not
always enlarged. They may be normal in size or small, pale, and granular.
The amyloid change is first seen in the Malpighian tufts, and then involves
the afferent and efferent vessels and the straight vessels. It may be confined
entirely to them. In later stages of the disease the tubules are affected, chiefly
the membrane, rarely, if ever, the cells themselves. In addition, the kidneys
always show signs of diffuse nephritis. The Bowman's capsules are thick-
ened, there may be glomerulitis, and the tubal epithelium is swollen, granular,
and fatty.
Symptoms. — The renal features alone may not indicate the presence of
this degeneration. Usually the associated condition gives a hint of the nature
of the process. The urine, as a rule, shows important changes; the quantity
is increased, and it is pale, clear, and of low specific gravity. The albumin is
usually abundant, but it may be scanty, and in rare instances absent. Pos-
sibly the variations in the situation of the amyloid changes may account for
this, since albumin is less likely to be present when the change is confined to
the vasa recta. In addition to ordinary albumin globulin may be present.
The tube-casts are variable, usually hyaline, often fatty or finely granular.
Occasionally the amyloid reaction can be detected in the hyaline casts. Dropsy
is present in many instances, particularly when there is much anaemia
or profound cachexia. It is not, however, an invariable symptom, and
there are cases in which it does not develop. Diarrhoea is a common accom-
paniment.
Increased arterial tension and cardiac hypertrophy are not usually pres-
ent, except in those cases in which amyloid degeneration occurs in the sec-
ondary contracted kidney; under which circumstances there may be ursemia
and retinal changes, which, as a rule, are not met with in other forms.
Diagnosis. — By the condition of the urine alone it is not possible to rec-
ognize amyloid changes in the kidney. Usually, however, there is no diffi-
culty, since the Bright's disease comes on in association with syphilis, pro-
longed suppuration, disease of the bone, or tuberculosis, and there is evidence
of enlargement of the liver and spleen. A suspicious circumstance is the
existence of polyuria with a large amount of albumin in the urine and few
casts, or when, in these constitutional affections, a large quantity of clear,
pale urine is passed, even without the presence of albumin.
The prognosis depends rather on the condition with which the nephritis i&
associated. As a rule it is grave.
IX. PYELITIS.
(Consecutive Nephritis ; Pyelonephritis ; Pyonephrosis.)
Definition. — Inflammation of the pelvis of the kidney and the conditions
which result from it.
Etiology. — Pyelitis in almost all cases is induced by bacterial invasion
and multiplication, rarely by the irritation of various substances such as tur-
pentine, cubebs, or sugar (diabetes). Normally the kidney can eliminate with-
out harm to itself, apparently, various bacteria carried to it by the blood-cur-
rent from the intestinal tract or some focus of infection; and it probably
704 DISEASES OF THE KIDNEYS.
becomes infected onh' where its resistance is lowered, as a resnlt of some gen-
eral cause, as ana?mia, malnutrition, or intercurrent disease, or of some local
cause, as nephritis, displacement, congestion due to pressure of neoplasms upon
the ureter, twisted ureter (Dietl's crisis), or of operation, or where the num-
ber or virulence of the micro-organisms is increased. These same factors prob-
ably play an important role also in the other common cau.se3 of pyelitis, ascend-
ing infection from an infected bladder (cystitis), and tuberculous infection.
Other causes described are various fevers, cancer, hydatids, the ova of certain
parasites, cold, and overexertion. Calculus seems not to be a common cause.
It is a not uncommon complication of pregnancy (French, Goulstonian Lec-
tures, 1908). In T. E. Brown's series of 20 cases, the colon bacillus was
obtained 7 times, the tubercle bacillus 6, the proteus bacillus 4, a white
staphylococcus twice, while in 1 case cultures were negative.
Morbid Anatomy. — In the early stages of pyelitis the mucous membrane
is turbid, somewhat swollen, and may show ecchymoses or a gra3dsh pseudo-
membrane. The urine in the pelvis is cloudy, and, on examination, numbers
of epithelial cells are seen.
In the calculous pyelitis there may be only slight turbidity of the mem-
brane, which has been called by some catarrhal pyelitis. More commonly the
mucosa is roughened, gra}ish in color, and thick. Under these circumstances
there is almost always more or less dilatation of the calyces and flattening of
the papillge. Following this condition there may be (a) extension of the sup-
purative process to the kidney itself, forming a pyelonephritis ; ( & ) a gradual
dilatation of the calyces with atrophy of the kidney substance, and finally the
production of the condition of pyonephrosis, in which the entire organ is rep-
resented by a sac of pus with or without a thin shell of renal tissue, (c) After
the kidney structure has been destroyed by suppuration, if the obstruction at
the orifice of the pelvis persists, the fluid portions may be absorbed and the
pus become inspissated, so that the organ is represented by a series of sacculi
containing grapsh, putty-like masses, which may become impregnated with
lime salts.
Tuberculous pyelitis, as already described, usualh^ starts upon the apices
of the p}Tamids, and may at first be limited in extent. Ultimately the condi-
tion produced may be similar to that of calculous pyelitis. Pyonephrosis is
quite as frequent a sequence, while the final transformation of the pus into
a putty-like material impregnated with salts, forming the so-called scrofulous
kidney, is even commoner.
The pyelitis consecutive to cystitis is generally bilateral, and the kidneys
are sometimes involved, forming the so-called surgical hidneys — acute suppura-
tive nephritis. There are lines of suppuration extending along the pyramids,
or small abscesses in the cortex, often just beneath the capsule; or there may
be wedge-shaped abscesses. The pus organisms either pass up the tubules or,
as Steven has shown, through the hinphatics.
Symptoms. — The forms associated with the fevers rarely cause any symp-
toms, even when the process is extensive. In mild grades there is pain in the
back or there may be tenderness on deep pressure on the affected side. The
urine, turbid and containing pus cells, some mucus, and occasional red blood-
cells, is acid or alkaline, depending on the infecting microbe; usually the albu-
minuria is of higher grade comparatively than the pjTiria.
PYELITIS. 705
Before the condition of pyuria is established there may be attacks of pain
on the affected side (not reaching the severe agony of renal colic), rigors, high
fever, and sweats. Under these circumstances the urine, which may have been
■clear, becomes turbid or smoky from the presence of blood, and may contain
large numbers of mucus cells and transitional epithelium. These cases are
not common, but I have twice had opportunity of studying such attacks for
a prolonged period. In one patient the occurrence of the rigor and fever could
sometimes be predicted from the change in the condition of the urine. Such
cases occur, I believe, in association with calculi in the pelvis.
The statement is not infrequently made that the epithelium in the urine
in pyelitis is distinctive and characteristic. This is erroneous, as may be read-
ily demonstrated by comparing scrapings of the mucosa of the renal pelvis and
■of the bladder. In both the epithelium belongs to what is called the transi-
tional variety, and in both regions the same conical, fusiform, and irregular
cells with long tails are found, and yet in pyelitis more of these tailed cells
occur, for in cystitis one must often search long for them.
When the pyelitis, whether calculous or tuberculous, has become chronic
and discharges, the symptoms are :
(1) Pyuria. — The pus is in variable amount, and may be intermittent.
Thus, as is often the case when only one kidney is involved, the ureter may be
temporarily blocked, and normal urine is passed for a time; then there is a
sudden outflow of the pent-up pus and the urine becomes purulent. Coin-
cident with this retention, a tumor mass may be felt on the side affected.
The pus has the ordinary characters, but the transitional epithelium is not so
abundant at this stage and comes from the bladder or from the pelvis of the
healthy side. Occasionally in rapidly advancing pyelonephritis, portions of
the kidney tissue, particularly of the apices of the pyramids, may slough away
and appear in the urine; or, as in a remarkable specimen shown to me by
Tyson, solid cheesy moulds of the calyces are passed. Casts from the kidney
tubules are sometimes present. The reaction of the urine depends entirely
upon the infecting microbe, whether the condition is unilateral or bilateral,
and whether the bladder is also infected, when vesical irritability and fre-
quent micturition may be present. Polyuria is usually present in the chronic
cases.
(3) Intermittent fever associated with rigors is usually present in cases
of suppurative pyelitis. The chills may recur at regular intervals, and the
cases are often mistaken for malaria. Owen-Eees called attention to the fre-
quent occurrence of these rigors, which form a characteristic feature of both
calculous and tuberculous pyelitis. Ultimately the fever assumes a hectic
type and the rigors may cease.
(3) The general condition of the patient often indicates prolonged sup-
puration. There is more or less wasting with anaemia and a progressive fail-
ure of health. Secondary abscesses may develop and the clinical picture be-
comes that of pyaemia. In some instances, particularly of tuberculous pyelitis,
the clinical course may resemble that of typhoid fever. There are instances
of pyuria recurring, at intervals, for many years without impairment of the
bodily vigor. Some of the chronic cases have practically no discomfort.
(4) Physical examination in chronic pyelitis usually reveals tenderness
on the affected side or a definite swelling, which may vary much in size and
46
706 DISEASES OF THE KIDNEYS.
■altimately attain large dimensions if the kidney becomes enormously distended.
as in pyonephrosis.
(5) Occasionally nervous symptoms, which may be associated with dysp-
noea, supervene, or the termination may be by coma, not unlike that of dia-
betes. These have been attributed to the absorption of the decomposing mate-
rials in the urine, whence the so-called ammonisemia. A form of paraplegia
has been described in connection with some cases of abscess of the kidney,
but whether due to a myelitis or to a peripheral neuritis has not yet been
determined.
In suppurative nephritis or surgical kidney following cystitis, the patient
complains of pain in the back, the fever becomes high, irregular, and asso-
ciated with chills, and in acute cases a typhoid state may precede the fatal
event.
Diagnosis. — Between the tuberculous and the calculous forms of pyelitis
it may be difficult or impossible to distinguish, except by the detection of
tubercle bacilli in the pus. The examination for bacilli should be made sys-
tematically, and in suspicious cases intraperitoneal injections of guinea-pigs
should also be made. From perinephric abscess pyonephrosis is distinguished
by the more definite character of the tumor, the absence of oedematous swell-
ing in the lumbar region, and, most important of all, the history of the case.
The urine, too, in perinephric abscess may be free from pus. There are cases,
however, in which it is difficult indeed to make a satisfactory diagnosis. A
patient, whom I saw with Fussell, had had cystitis through her pregnancy,
subsequently pus in the urine for several months, and then a large fluctuating
abscess developed in the right lumbar region. It did not seem possible, either
before or during the operation, to determine whether the case was a simple
pyonephrosis or whether there had been a perinephric abscess caused by the
pyelitis.
Suppurative pyelitis and cystitis are apt to be confounded, and perineal
section is not infrequently performed on the supposition of the existence of
the latter. The two conditions may, of course, coexist and prove puzzling,
but the history, the higher relative grade of albuminuria in pyelitis (Eosen-
feld, Goldberg, T. E. Brown), the polyuria, the mode of development, the
local signs in one lumbar region, and the absence of pain in the bladder, should
be sufficient to differentiate the affections. In women, by catheterization of
the ureters, it may be definitely determined whether the pus comes from the
kidneys or from the bladder. The cystoscope may be used for this purpose.
Prognosis. — Cases coming on during the fevers usually recover. Tuber-
culous pyelitis may terminate favorably by inspissation of the pus and con-
version into a putty-like substance with deposition of lime salts. With pyo-
nephrosis the dangers are increased. Perforation may occur into the perito-
naeum, the patient may be worn out by the hectic fever, or amyloid disease may
develop.
Treatment. — In mild cases fluids should be taken freely, particularly the
alkaline mineral waters, to which potassium citrate may be added.
The treatment of the calculous form will be considered later. Practically
there are no remedies which have much influence upon the pyuria. Some
of the recently described urinary antiseptics, as urotropin, etc., seem to be of
value, especially in the acute cases. Tonics should be given, a nourishing
HYDRONEPHROSIS. 707
diet, and milk and butter-milk may be taken freely. When the tumor has
formed or even before it is perceptible, if the symptoms are serious and severe,
the kidney should be explored, and, if necessary, nephrotomy or nephrectomy
should be performed.
X. HYDRONEPHROSIS.
Definition. — Dilatation of the pelvis and calyx of the kidney with atrophy
of its substance, caused by the accumulation of non-purulent fluids, the result
of obstruction.
Etiology. — The condition may be congenital, owing to some abnormality
in the ureter or urethra. The tumor produced may be large enough to retard
labor. Sometimes it is associated with other malformations. There is a
condition of moderate dilatation, apparently congenital, which is not connected
with any obstruction in the ducts.
In some instances there has been contraction or twisting of the ureter,
or it has been inserted into the kidney at an acute angle or at a high level.
In adult life the condition may be due to lodgment of a calculus, or to a cica-
tricial stricture following ulcer.
There is a remarkable condition of hypertrophy and dilatation of the
bladder and ureters associated with congenital defect of the abdominal mus-
cles. The bladder may form a large abdominal tumor and the ureters may be
as large and visible as coils of the small intestine.
New growths, such as tubercle or cancer, occasionally induce hydronephro-
sis; more commonly, pressure upon the ureter from without, particularly
tumors of the ovaries and uterus. Occasionally cicatricial bands compress the
ureter. Obstruction within the bladder may result from cancer, from hyper-
trophy of the prostate with cystitis, and in the urethra from stricture. It is
stated that slight grades of hydronephrosis have been found in patients with
excessive polyuria.
In whatever way produced, when the ureter is blocked the secretion accu-
mulates in the pelvis and infundibula. Sometimes acute inflammation fol-
lows, but more commonly the slow, gradual pressure causes atrophy of the
papillffi with gradual distention and wasting of the organ. In acquired cases
from pressure, even when dilatation is extreme, there may usually be seen a
thin layer of renal structure. In the most extreme stages the kidney is repre-
sented by a large cyst, which may perhaps show on its inner surface imperfect
septa. The fluid is thin and yellowish in color, and contains traces of urinary
salts, urea, uric acid, and sometimes albumin. The secretion may be turbid
from admixture with small quantities of pus.
Total occlusion does not always lead to a hydronephrosis, but may be fol-
lowed by atrophy of the kidney. It appears that when the obstruction is inter-
mittent or not complete the greatest dilatation is apt to follow. The sac may
be enormous, and cause an abdominal tumor of the largest size. The condition
has even been mistaken for ascites. Enlargement of the other kidney may
compensate for the defect. Hypertrophy of the left side of the heart usually
follows.
Symptoms. — When small, it may not be noticed. The congenital cases
when bilateral usually prove fatal within a few days; when unilateral, the
708 DISEASES OF THE KIDNEYS.
tumor may not be noticed for some time. It increases progressively and has
all the characters of a tumor in the renal region. In adult life many of the
cases, due to pressure by tumors, as in cancer of the uterus and enlargement
of the prostate, etc., give rise to no symptoms.
There are remarkable instances of intermittent hydronephrosis in which
the tumor suddenly disappears with the discharge of a large quantity of
clear fluid. The sac gradually refills, and the process may be repeated for
years. In these cases the obstruction is unilateral ; a cicatricial stricture exists,
or a valve is present in the ureter, or the ureter enters the upper part of the
pelvis. Many of the cases are in women and associated with movable kidney.
The examination of the abdomen shows, in unilateral hydronephrosis, a
tumor occupying the renal region. When of moderate size it is readily recog-
nized, but when large it may be confounded with ovarian or other tumors.
In young children it may be mistaken for sarcoma of the kidney or of the
retroperitoneal glands, the common cause of abdominal tumor in early life.
Aspiration alone would enable us to differentiate between hydronephrosis and
tumor. The large hydronephrotic sac is frequently mistaken for ovarian
tumor. The latter is, as a rule, more mobile, and rarely fills the deeper por-
tion of the lumbar region so thoroughly. The ascending colon can often be
detected passing over the renal tumor, and examination per vaginam, particu-
larly under ether, will give important indications as to the condition of the
ovaries. In doubtful cases the sac should be aspirated. The fluid of the renal
cyst is clear, or turbid from the presence of cell elements, rarely colloid in char-
acter ; the specific gravit}^ is low ; albumin and traces of urea and uric acid are
usually present ; and the epithelial elements in it may be similar to those found
in the pelvis of the kidney. In old sacs, however, the fluid may not be char-
acteristic, since the urinary salts disappear, but in one case of several years'
duration oxalates of lime and urea were found.
Perhaps the greatest difiiculty is offered by the condition of hydronephrosis
in a movable kidney. Here, the history of sudden disappearance of the tumor
with the passage of a large quantity of clear fluid would be a point of great
importance in the diagnosis. In those rare instances of an enormous sac fill-
ing the entire abdomen, and sometimes mistaken for ascites, the character of
the fluid might be the only point of difference. The tumor of pyonephrosis
may be practically the same in physical characteristics. Fever is usually
present, and pus is often found in the urine. In these cases, when in doubt,
exploratory puncture should be made.
The outlook in hydronephrosis depends much upon the cause. When sin-
gle, the condition may never produce serious trouble, and the intermittent
eases may persist for years, and finally disappear. Occasionally the cyst rup-
tures into the peritonaeum, more rarely through the diaphragm into the lung.
A remarkable case of this kind was under the care of my colleague, Halsted.
A man, aged twenty-one, had, from his second year, attacks of abdominal pain
in which a swelling would appear between the hip and costal margin and sub-
side with the passage of a large amount of urine. In January, 1888, the sac
discharged through the right lung. Reaccumulations occurred on several
occasions, and on June 9, 1891, the sac was opened and drained. He remains
well, though there is still a sinus through which a clear, probably urinous,
fluid is discharged.
NEPHROLITHIASIS. 709
The sac may discharge spontaneously through the ureter and the fluid
never reaccumulate. In bilateral hydronephrosis there is a danger that uraemia
may supervene. There are instances, too, in which blocking of the ureter on
the soimd side by calculus has been followed by urasmia. And, lastly, the sac
may suppurate, and the condition change to one of pyonephrosis.
Treatment. — Cases of intermittent hydronephrosis which do not cause
serious symptoms should be let alone. It is stated that, in sacs of moderate
size, the obstruction has been overcome by shampooing. If practised, it should
be done with great care. When the sac reaches a large size aspiration may be
performed and repeated if necessary. Puncture should be made in the flank,
midway between the ilium and the last rib. If the fluid reaccumulates and
the sac becomes large, it may be incised and drained, or, as a last resort, the
kidney may be removed. In women a carefully adapted pad and bandage will
sometimes prevent the recurrence of an intermittent hydronephrosis.
XI. NEPHROLITHIASIS (Renal Calculus).
Definition.^The formation in the kidney or in its pelvis of concretions,
by the deposition of certain of the solid constituents of the urine.
Etiology and Pathology. — In the kidney substance itself the separation
of the urinary salts produces a condition to which, unfortunately, the term
infarct has been applied. Three varieties may be recognized: (1) The uric-
acid infarct, usually met with at the apices of the pyramids in new-born chil-
dren and during the first weeks of life. The priapism and attacks of cry-
ing in the new-born have been attributed to the passage of these infarcts
(Southworth) ; (2) the sodium-urate infarct, sometimes associated with
ammonium urate, which forms whitish lines at the apices of the pyra-
mids and is met with chiefly, but not always, in gouty persons; and (3) the
lime infarcts, forming very opaque white lines in the pyramids, usually in
old people.
In the pelvis and calyces concretions of the following forms occur: (a)
Small gritty particles, renal sand, ranging in size from the individual grains
of the uric-acid sediment to bodies 1 or 3 mm. in diameter. These may be
passed in the urine for long periods without producing any symptoms, since
they are too fine to be arrested in their downward passage.
(&) Larger concretions, ranging in size from a small pea to a bean, and
either solitary or multiple in the calyces and pelvis. It is the smaller of these
calculi which, in their passage, produce the attacks of renal colic. They may
be rounded and smooth, or present numerous irregular projections.
(c) The dendritic form of calculus. The orifice of the ureter may be
blocked by a Y-shaped stone. The pelvis itself may be occupied by the con-
cretion, which forms a more or less distinct mould. These are the remark-
able coral calculi, which form in the pelvis complete moulds of infundibula
and calyces, the latter even presenting cup-like depressions corresponding to
the apices of the papillae. Some of these casts in stone of the renal pelvis are
as beautifully moulded as HyrtFs corrosion preparations.
Chemically the varieties of calculi are : ( 1 ) Uric acid and urates, most
important, and forming the renal sand, the small solitary, or the large dendritic
stones. They .are very hard, the surface is smooth, and the color reddish.
710 DISEASES OF THE KIDNEYS.
The larger stones are usually stratified and very dense. ITsually the uric
acid and the urates are mixed, but in children stones composed of urates alone
may occur.
(3) Oxalate of lime, which forms mulberry-shaped calculi, studded with
points and spines. They are often very dark in color, intensely hard, and
are a mixture of oxalate of lime and uric acid.
(3) Phosphatic calculi are composed of the calcium phosphate and the
ammonio-magnesium phosphate, sometimes mixed with a small amount of
calcium carbonate. They are quite common, although the phosphatic salts
are often deposited about the uric acid or the calcium-oxalate stones.
(i) Rare forms of calculi are made up of cystine, xanthine, carbonate of
lime, indigo, and urostealith.
The mode of formation of calculi has been much discussed. They may
be produced by an excess of a sparingly soluble abnormal ingredient, such
as cystine or xanthine; more frequently by the presence of uric acid in a
very acid urine which favors its deposition. Sir William Eoberts thus briefly
states the conditions which lead to the formation of the uric-acid concretions :
high acidity, poverty in salines, low pigmentation, and high percentage of
uric acid. Ord suggests that albumin, mucus, blood, and epithelial threads
may be the starting-point of stone. The demonstration of organisms in the
centre of renal calculi renders it probable that in many cases the nucleus of
the stone is an agglutinated mass of bacteria.
Eenal calculi are most common in the early and later periods of life. They
are moderately frequent in this country, but there do not appear to be spe-
cial districts, corresponding to the " stone counties " in England. Men are
more often affected than women. Sedentary occupations seem to predispose
to stone.
The effects of the calculi are varied. It is by no means uncommon to find
a dozen or more stones of various sizes in the calyces without any destruction
of the mucous membrane or dilatation of the pelvis. A turbid urine fills the
pelvis in which there are numerous cells from the epithelial lining. There
are cases of this sort in which, apparently, the stones may go on forming
and are passed for years without seriously impairing the health and without
inconvenience, except the attacks of renal colic. Still more remarkable are the
cases of coral-like calculi, which may occupy the entire pelvis and calyces with-
out causing pyelitis, but wliich gradually lead to more or less induration of
the kidney. The most serious effects are when the stone excites a suppura-
tive pyelitis and pyonephrosis.
Symptoms. — Patients may pass gravel for years without having an attack
of renal colic, and a stone may never lodge in the ureter. In other instances,
the formation of calculi goes on year by year and the patient has recurring
attacks such as have been so graphically described by ]\Iontaigne in his own
case. A patient may pass an enormous number of calculi. Some years ago
I was consulted by a commercial traveller, an extremely vigorous man, who
for many years had had repeated attacks of renal colic, and had passed several
hundred calculi of various sizes. His collection filled an ounce bottle. A
patient may pass a single calculus, and never be troubled again. The large
coral calculi may excite no s^Tiiptoms. In a remarkable specimen of the kind,
presented to the McGill Medical Museum by J. A. Macdonald, the patient.
NEPHROLITHIASIS. 7 1 1
a middle-aged woman, died suddenly with ursemie symptoms. There was no
pyelitis, but the kidneys were sclerotic.
Renal, colic ensues when a stone enters the. ureter, or follows an acute pyeli-
tis. An attack may set in abruptly without apparent cause, or may follow
a strain in lifting. It is characterized by agonizing pain, which starts in the
flank of the affected side, passes down the ureter, and is felt in the testicle
and along the inner side of the thigh. The pain may also radiate through
the abdomen and chest, and be very intense in the back. In severe attacks
there are nausea and vomiting and the patient is collapsed. The perspiration
breaks out upon the face and the pulse is feeble and quick. A chill may pre-
•cede the outbreak, and the temperature may rise as high as 103°. No one
has more graphically described an attack of " the stone " than Montaigne,*
who was a sufferer for many years : " Thou art seen to sweat with pain, to
look pale and red, to tremble, to vomit well-nigh to blood, to suffer strange
contortions and convulsions, by starts to let tears drop from thine eyes, to
urine thick, black, and frightful water, or to have it suppressed by some sharp
and craggy stone, that cruelly pricks and tears thee." The symptoms persist
for a variable period. In short attacks they do not last longer than an hour;
in other instances they continue for a day or more, with temporary relief.
Micturition is frequent, occasionally painful, and the urine, as a rule, is
bloody. There are instances in which a large amount of clear urine is passed,
probably from the other kidney. In rare cases the secretion of urine is com-
pletely suppressed, even when the kidney on the opposite side is normal, and
death may occur from uremia. This most frequently happens when the second
kidney is extensively diseased, or when only a single kidney exists. A num-
ber of cases of this kind have been recorded. The condition has been termed,
by Sir William Eoberts, obstructive suppression. It is met with also when
cancer compresses both ureters or involves their orifices in the bladder. The
patient may not appear to be seriously ill at first, and ursemie symptoms may
not develop for a week, when twitching of the muscles, great restlessness, and
sometimes drowsiness supervene, but, strange to say, neither convulsions nor
coma. Death takes place usually within twelve days from the onset of the
obstruction.
After the attack of colic has passed there is more or less aching on the
affected side, and the patient can usually tell from which kidney the stone
has come. Examination during the attack is usually negative. Very rarely
the kidney becomes palpable. Tenderness on the affected side is common.
In very thin persons it may be possible, on examination of the abdomen, to
feel the stone in the ureter ; or the patient may complain of a grating sensation.
When the calculi remain in the kidney they may produce very definite and
characteristic symptoms, of which the following are the most important :
(1) Pain^ usually in the back, which is often no more than a dull soreness,
but which may be severe and come on in paroxysms. It is usually on the
side affected, but may be referred to the opposite kidney, and there are in-
stances in which the pain has been confined to the sound side. It radiates
in the direction of the ureter, and may be felt in the scrotum or even in the
penis. Pains of a similar nature may occur in movable kidneys, and there are
* Essays, Book III, 13.
712 DISEASES OF THE KIDNEYS.
several instances on record in which surgeons have incised the kidney for
stone and found none. In an instance in which pain was present for a couple
of years the exploration revealed only a contracted kidney.
(2) HcBmaturia. — Although this occurs most frequently when the stone
becomes engaged in the ureter, it may also come on when the stones are in
the pelvis. The bleeding is seldom profuse, as in cancer, but in some instances
may persist for a long time. It is aggravated by exertion and lessened by rest.
Frequently it onl}^ gives to the urine a smok}^ hue. The urine may be free for
days, and then a sudden exertion or a prolonged ride may cause smokiness,
or blood may be passed in considerable quantities.
(3) Pyelitis. — (a) There may be attacks of severe pain in the back, not
amounting to actual colic, which are initiated by a heavy chill followed by
fever, in which the temperature may reach lO-i" or 105°, followed by profuse
sweating. The urine, which has been clear, may become turbid and smoky
and contain blood and abundant epithelium from the pelvis. Attacks of this
description may recur at intervals for months or even years, and are generally
mistaken for malaria, unless special attention is paid to the urine and to the
existence of the pain in the back. This renal intermittent fever, due to the
presence of calculi, is analogous to the hepatic intermittent fever, due to
gall-stones, and in both it is important to remember that the most intense
paroxysms may occur without any evidence of suppuration.
( h ) More frequently the s}Tnptoms of purulent pyelitis, which have already
been described, are present; pain in the renal region, recurring chills, and
pus in the urine, with or without indications of pyonephrosis.
(4) Pyuria. — There are instances of stone in the kidney in which pus
occurs continuously or intermittently in the urine for many years. On many
occasions between 1875 and 1884 I examined the urine of a physician who had
passed calculi when a student in 1845, and had pus in the urine at intervals
to 1891. In spite of the prolonged suppuration he had remarkable mental
and bodily vigor.
Patients with stone in the kidney are often robust, high livers, and gouty.
Attacks of dyspepsia are not uncommon, or they may have severe headaches.
Diagnosis. — Eenal may be mistaken for intestinal colic, particularly if the
distention of the bowels is marked, or for biliary colic. The situation and
direction of the pain, the retraction and tenderness of the testicle, the occur-
rence of haematuria, and the altered. character of the urine are distinctive fea-
tures. Attention may again be called to the fact that attacks simulating renal
colic are associated with movable kidney, or even, it has been supposed, without
mobility of the kidney, with the accumulation of the oxalates or uric acid in
the pelvis of the kidney. The diagnosis between a stone in the kidney and
stone in the bladder is not always easy, though in the latter the pain is
particularly about the neck of the bladder, and not limited to one side. In
the uric-acid or uratic renal stone, the urine is acid, thus aiding us in differ-
entiating it from a bladder stone, when alkaline urine is the rule. It is
stated that certain differences occur in the" sjnnptoms produced by different
sorts of calculi. The large uric-acid calculi less frequently produce severe
sjrtnptoms. On the other hand, as the oxalate of lime is a rougher calculus,
it is apt to produce more pain (often of a radiating character) than the
lithic-acid form, and to cause haemorrhage. In both these forms the urine
TUMORS OF THE KIDNEY. 713
is acid. The phosphatic calculi are stated to produce the most intense pain,
and the urine is commonly alkaline. The Eoentgen rays are becoming of more
and more value in determining the presence and position of a stone.
Treatment. — In the attacks of renal colic great relief is experienced by
the hot bath, which is sometimes sufficient to relax the spasm When the pain
is very intense morphia should be given hypodermically and inhalations of
chloroform may be necessary until the effects of the anodyne are manifest.
Local applications are sometimes grateful — hot poultices, or cloths wrung out
of hot water. The patient may drink freely of hot lemonade, soda water, or
barley water. Occasionally change in posture or inversion will give great
relief. Surgical interference should be considered in all cases, especially when
the stone is large or the associated pyelitis severe.
In the intervals the patient should, as far as possible, live a quiet life,
avoiding sudden exertion of all sorts. The essential feature in the treatment
is to keep the urine abundant and, in the uric-acid or uratic cases, alkaline.
The patient should drink daily a large but definite quantity of mineral waters *
or distilled water, which is just as satisfactory. The citrate or bicarbonate of
potash may be added. The aching pains in the back are often greatly relieved
by this treatment. Many patients find benefit from a stay at Saratoga, Bed-
ford, Poland, or other mineral springs in the United States, or at Vichy or
Ems in Europe.
The diet should be carefully regulated, and similar to that indicated in the
early stages of gout. Sir William Eoberts recommends what is known as the
solvent treatment for uric-acid calculi. The citrate of potash is given in large
doses, half a drachm to a drachm, every three hours in a tumblerful of water.
This should be kept up for several months. I have had no success with this
treatment, nor, when one considers the character of the uric-acid stones
usually met with in the kidney, does it seem likely that any solvent action
could be exercised upon them by changes in the urine. This treatment should
be abandoned if the urine becomes ammoniacal.
The value of piperazine as a solvent of uric-acid gravel or of uric-acid
stones has been much discussed of late. While outside the body a watery solu-
tion of the drug has this power in a marked degree, the amount excreted in
the urine as given in the ordinary doses of 15 grains daily seems to have very
little influence. Several observers have shown that the percentage of piper-
azine excreted in the urine, when taken in doses of from 1 to 3 grammes, has,
when tested outside of the body, little or no influence as a solvent (Fawcett,
Gordon) .
XII. TUMORS OF THE KIDNEY.
These are benign and malignant. Of the benign tumors, the most com-
mon are the small nodular fibromata which occur frequently in the pyra-
mids, and occasionally lipoma, angioma, or lymphadenoma. The adenomata
may be congenital. In one of my cases the kidneys were greatly enlarged,
contained small cysts, and numerous adenomatous structures throughout both
organs.
* Some of these, if we judge by the laudatory reports, are as potent as the waters of Cor-
sena, declared by Montaigne to be " powerful enough to break stones."
714 DISEASES OF THE KIDNEYS.
Malignant growths — cancer or sarcoma — may be either primary or second-
ary. The sarcomata are the most common, either alveolar sarcoma or the
remarkable form containing striped muscular fibres — rhabdomyoma. They
are very common tumors in children. One of the most common and important
renal tumors is the hypernepliroma, growing in or upon the organ from the
adrenal tissue — the aberrant " rests " of Grawitz. A. 0. J. Kelly, Eamsay,
and Ellis have made important contributions to our knowledge of this form.
Of 163 cases only 6 were extra-renal (Ellis). They may be small and in the
renal cortex or form large tumors with extensive metastases, particularly
in the lungs. Kelly states that most of the primary carcinomas and alveolar
sarcomas of the kidney are really hypernephromata.
The tumors attain a very large size, and almost fill the abdomen. In chil-
dren they may be enormous. Morris states that in a boy at the Middlesex Hos-
pital the tumor weighed 31 pounds. They grow rapidly, are often soft, and
haemorrhage frequently takes place into them. In the sarcomata, invasion of
the pelvis or of the renal vein is common. The rhabdomyomata rarely form
very large tumors, and death occurs shortly after birth. In one of my cases
the child at the age of three years and a half died suddenly of embolism of
the pulmonary artery and tricuspid orifice by a fragment of the tumor, which
had grown into the renal vein.
Symptoms. — The following are the most important: (1) Haematuria in
one-half the cases, which may be the first indication. The blood is fluid or
clotted, and there may be very characteristic moulds of the pelvis of the kidney
and of the ureter. It would no doubt be possible for such to form in the
hsematuria from calculus, but I have never met with a case of blood-casts
of the pelvis and of the ureter, either alone or together, except in cancer. It
is rare indeed that cancer elements can be recognized in the urine, and yet
the diagnosis has been made in this way.
(3) Pain is an uncertain symptom. In several of the largest tumors which
have come under my observation there has been no discomfort from beginning
to close. When present, it is of a dragging, dull character, situated in the
flank and radiating down the thigh. The passage of the clots may cause great
pain. In one case the growth was at first upward, and the symptoms for some
months were those of pleurisy.
(3) Progressive emaciation. The loss of flesh is usually marked and
advances rapidly. There may, however, be a very large tumor without
emaciation.
Physical Sigxs. — In almost all instances tumor is present. When small
and on the right side, it may be very movable; in some instances, occupying
a position in the iliac fossa, it has been mistaken for ovarian tumor. The
large growths fill the flank and gradually extend toward the middle line,
occupying the right or left half of the abdomen. Inspection may show two or
three hemispherical projections corresponding to distended sections of the
organ. In children the abdomen may reach an enormous size and the veins
are prominent and distended. On bimanual palpation the tumor is felt to
occupy the lumbar region and can usually be lifted slightly from its bed; in
some cases it is very movable, even when large ; in others it is fixed, firm, and
solid. The respiratory movements have but slight influence upon it. Eapidly
growing renal tumors are soft, and on palpation may give a sense of fluctua-
CYSTIC DISEASE OF THE KIDNEY. 715
tion. A point of considerable importance is the fact that the colon crosses the.
tumor, and can usually be detected without difficulty.
Diagnosis. — In children very large abdominal tumors are either renal or
retroperitoneal. The retroperitoneal sarcoma (Lobstein's cancer) is more cen-
tral, but may attain as large a size. If the case is seen only toward the end, a
differential diagnosis may be impossible ; but as a rule the sarcoma is less mov-
able. It is to be remembered that these tumors may invade the kidney. On
the left side an enlarged spleen is readily distinguished, as the edge is very
distinct and the notch or notches well marked ; it descends during respiration,
and the colon lies behind, not in front of it. On the right side growths of the
liver are occasionally confounded with renal tumors; but such instances are
rare, and there can usually be detected a zone of resonance between the upper
margin of the renal tumor and the ribs. Late in the disease, however, this is
not possible, for the renal tumor is in close union with the liver.
A malignant growth in a movable kidney may be very deceptive and may
simulate cancer of the ovary or myoma of the uterus. The great mobility
upward of the renal growth and the negative result of examination of the
pelvic viscera are the reliable points.
When the growth is small and the patient in good condition removal of the
organ may be undertaken, but the percentage of cases of recovery is very small,
only 5.4 per cent (Gr. Walker).
XIII. CYSTIC DISEASE OF THE KIDNEY.
The following varieties of cysts are met with :
I. The small cysts, already described in connection with the chronic
nephritis, which result from dilatation of obstructed tubules or of Bowman's
capsules. There are cases very difficult to classify, in which the kidneys are
greatly enlarged, and very cystic in middle-aged or elderly persons, and yet
not so large as in the congenital form.
II. Solitary cysts, ranging in size from a marble to an orange, or even
larger, are occasionally found in kidneys which present no other changes. In
exceptional cases, they may form tumors of considerable size. Newman oper-
ated on one which contained 25 ounces of blood. They, too, in all probability,
result from obstruction.
III. The polycystic kidneys in which the greatly enlarged organs, weighing
even as much as six pounds, are represented by a conglomeration of cysts, vary-
ing in size from a pea to a marble. Little or no renal tissue may be noticeable,
although in microscopical sections it is seen that a considerable amount re-
mains in the interspaces. The cysts contain a clear or turbid fluid, sometimes
reddish-brown or even blackish in color, and may be of a colloidal consistence.
Albumin, blood crystals, cholesterin, with triple phosphates and fat drops are
found in the contents. Urea and uric acid are rarely present. The cysts
are lined by a flattened epithelium. They occur in the foetus, and sometimes
are of such a size as to obstruct labor. In the adult they are usually bilateral,
and there is every reason to believe that they begin in early life and increase
gradually. Indeed, a progressive growth has been noticed in some cases (Alfred
King). They may be found in connection with cystic disease of the liver and
other organs. It is difficult to account for the origin of this remarkable con-
716 DISEASES OF THE KIDNEYS.
dition^ which some regard as a defect of development rather than a patho-
logical change, and point to the association in the fatal cases of other anoma-
lies, as imperforate anus, Shattock and Bland Sutton have suggested that
the anomaly of development is a failure of complete differentiation of the
Wolffian bodies, but embryologists whom I have consulted on this point tell
me that this is most unlikely. Others believe the condition to be a new growth
— a sort of mucoid endothelioma.
It is interesting to note that several members of a family may be affected.
I have reported an instance in which mother and son were the subjects of
the disease.
Symptoms. — Of five cases which I have seen in adults the condition was
recognized during life in four. The features are characteristic.
(a) Bilateral tumors in the renal regions, which may increase in size
under observation. They may cause great enlargement of the upper zone of
the abdomen. The colon and stomach are in front of the tumors, on the
surface of which in very thin subjects thie cysts may be palpable.
(&) Haematuria, which may recur at intervals for years.
(c) The signs of a chronic interstitial nephritis — (1) pallor or muddy
complexion; in rare instances a bronzing of the skin; (2) sclerosis of the
arteries; (3) hypertrophy of the heart with accentuated second sounds;
(4) urine abundant, of low specific gravity, with albumin, and hyaline and
granular tube-casts, and in one of my cases there were cholesterin crystals.
Death occurs from urasmia or the cardio-vascular complications of chronic
Bright's disease. A rare event is rupture of a cyst with the formation of a
perinephric abscess and peritonitis. In two of my cases the skin became much
pigmented.
While both kidneys are, as a rule, involved, one may be much smaller than
the other.
Operation is rarely indicated, unless the condition is found to be uni-
lateral, in which case Morris has removed the kidney in several instances, and
the patients have remained well for years.
IV. Occasionally the kidneys and liver present numerous small cysts scat-
tered through the substance. The spleen and the thyroid also may be involved,
and there may be congenital malformation of the heart. The cysts in the
kidney are small, and neither so numerous nor so thickly set as in the con-
glomerate form, though in these cases the condition is probably the result of
some congenital defect. There are cases, however, in which the kidneys are
very large. It is more common in the lower animals than in man. I have
seen several instances of it in the hog ; in one case the liver weighed 40 pounds,
and was converted into a mass of simple cysts. The kidneys were less involved.
Charles Kennedy found references to 12 cases of combined cystic disease of the
liver and kidneys.
The echinoccocus cysts have been described under the section on parasites.
Paranephric cysts (external to the capsule) are rare; they may reach a large
size.
PERINEPHRIC ABSCESS. 717
XIV. PERINEPHRIC ABSCESS.
Suppuration in the connective tissue about the kidney may follow (1)
blows and injuries; (2) the extension of inflammation from the pelvis of the
kidney, the kidney itself, or the ureters; (3) perforation of the bowel, most
commonly the appendix, in some instances the colon; (4) extension of sup-
puration from the spine, as in caries, or from the pleura, as in empyema ; ( 5 )
as a sequel of the fevers, particularly in children.
Post mortem the kidney is surrounded by pus, particularly at the posterior
part, though the pus may lie altogether in front, between the kidney and the
peritonaeum. Usually the abscess cavity is extensive. The pus is often offen-
sive and may have a distinctly fgecal odor from contact with the large bowel.
It may burrow in various directions and burst into the pleura and be dis-
charged through the lungs. A more frequent direction is down the psoas
muscle, when it appears in the groin, or it may pass along the iliacus fascia
and appear at Poupart's ligament. It may perforate the bowel or rupture into
the peritonaeum ; sometimes it penetrates the bladder or vagina.
Post mortem we occasionally find a condition of chronic perinephritis in
which the fatty capsule of the kidney is extremely firm, with numerous bands
■of fibrous tissue, and is stripped off from the proper capsule with the greatest
difficulty. Such a condition probably produces no symptoms.
Symptoms. — There may be intense pain, aggravated by pressure, in the
lumbar region. In other instances, the onset is insidious, without pain in the
renal region ; on examination signs of deep-seated suppuration may be detected.
On the affected side there is usually pain, which may be referred to the neigh-
borhood of the hip-joint or to the joint itself, or radiate down the thigh and be
associated with the retraction of the testis. The patient lies with the thigh
flexed, so as to relax the psoas muscle, and in walking throws, as far as pos-
sible, the weight on the opposite leg. He also keeps the spine immobile,
assumes a stooping posture in walking, and has great difficulty in voluntarily
addueting the thigh (Gibney).
There may be pus in the urine if the disease has extended from the pelvis
or the kidney, but in other forms the urine is clear. When pus has formed
there are usually chills with irregular fever and sweats. On examination,
deep-seated induration is felt between the last rib and the crest of the ilium.
Bimanual palpation may reveal a distinct tumor mass. (Edema or puffiness
of the skin is frequently present.
Dia^osis. — The diagnosis is usually easy; when doubt exists the aspirator
needle should be used. We can not always differentiate the primary forms
from those due to perforation of the kidney or of the bowel. This, however,
makes but little difference, for the treatment is identical. It is usually pos-
sible by the history and examination to exclude diseases of the vertebra. In
children hip- joint disease may be suspected, but the pain is higher, and there
is no fulness or tenderness over the hip-joint itself.
The treatment is clear — early, free, and permanent drainage.
SECTION VIII.
DISEASES OF THE BLOOD A^D DUCTLESS
GLANDS.
I. ANiEMIA.
Definition. — Anaemia may be defined as a reduction in the amount of the
blood as a whole or of its corpuscles, oligocythaemia, or of certain of its more
important constituents, such as albumin and haemoglobin.
Pseudo-Ancemia. — The state of the skin and mucous membranes is usually
a safe guide in judging of the presence of anaemia. There are certain con-
ditions in which this is deceptive, and a marked pallor may exist with nearly
normal corpuscles and hemoglobin. ( 1 ) The pallor of nausea and the anaemia
following a drinking-bout (Katzenjammer !) ; (2) the apparent anaemia of
Bright's disease, of certain cases of heart disease, of early arterio-sclerosis
(Stengel); (3) of the morphia hahitue, sometimes of the lead worker; and
(4) of certain perfectly healthy individuals who are, so to speak, born pale
and stay pale — these are some of the conditions in which vdth a pseudo-
anaemia there is a normal or nearly normal blood-count and color index.
Anaemia may. be local or general.
Local Anaemia. — Tissue irrigation with blood is primarily from the heart,
but in all extensive systems of this sort provision is made at the local terri-
tories for variations in the supply, according to the needs of a part. The
sluices are arranged by means of the stop-cock action of the arteries, which
contract or expand under the iniluence of the vaso-motor ganglia, central and
'peripheral. If the sluices of one large district are too widely open, so much
blood may enter that other important regions have not enough to keep them
at work. Local anaemia of the brain, causing swooning, ensues when the
mesenteric channels, capable of holding all the blood of the body, are wide
open. Emotional stimuli, reflex from pain, etc., removal of pressure, as after
tapping in ascites, may cause this. It is probable that many of the nervous
and other symptoms in enteroptosis are due to the relative anaemia of the
cerebral and spinal systems, owing to the persistent overflowing of the mesen-
teric reservoir. We know very little of local anaemia of the various organs,
but possibly functional disturbance in the liver, kidneys, pancreas, heart, etc.,
may result from a permanently low pressure in the local blood " mains."
Anaemia from spasm of the arterial walls is seen in Eaynaud's disease, which
usually affects the peripheral vessels, causing local syncope of the fingers, but
it may occur in the visceral vessels, particularly of the brain, and cause tem-
porary hemiplegia, aphasia, etc.
718
ANjEMIA. 719
General anaemia may be: (1) Secondary or symptomatic; (2) primary,
essential, or cytogenic.
Secondary Anemia.
Under this division comes a large proportion of all cases. The following
are the most important groups, based on the etiology :
(1) Ansemia from hsemorrhage, either traumatic or spontaneous. The
loss of blood may be rapid, as in lesions of large vessels, in injury or in rup-
ture of aneurisms, in ulcer of the stomach or duodenum, or in post-partum
haemorrhage. If the loss is excessive, death results from lowering of the
arterial pressure. In sudden profuse haemorrhage the loss of 3 or 4 pounds
of blood may prove fatal. In the rupture of an aneurism into the pleura the
loss of blood may amount to 7^ pounds, the largest quantity I have known to
be shed into one cavity. In a case of haematemesis the patient lost over 10
pounds of blood in one week and yet recovered from the immediate effects.
Even after very severe haemorrhage the number of red blood-corpuscles is not
reduced so greatly as in forms of idiopathic anaemia. Thus in one case Just
mentioned, at the termination of the week of bleeding there were nearly
1,390,000 red blood-corpuscles to the cubic millimetre. The process of regen-
eration goes on with great rapidity, and in some " bleeders " a week or ten
days suffice to re-establish the normal amount. The watery and saline con-
stituents of the blood are readily restored by absorption from the gastro-
intestinal tract. The albuminous elements also are quickly renewed, but it
may take weeks or months for the corpuscles to reach the normal standard.
The haemoglobin is restored more slowly than the corpuscles. Chart XVI,
page 720, illustrates the rapid fall and gradual restitution in a case of
severe purpura hemorrhagica. In September the blood-count was : red blood-
corpuscles, 5,350,000; leucocytes, 5,500; hemoglobin, 94 per cent.
The microscopical characters of the blood after severe hemorrhage may
not be greatly changed. The red corpuscles show, usually, rather more
marked differences in size than normally, while the average size may be a
trifle reduced; there may be a moderate poikilocytosis. The corpuscles are
paler than normally. Nucleated red corpuscles appear, almost always, soon
after the haemorrhage; they are, however, not numerous, except when their
large number indicates the so-called blood crisis. These are small bodies of
about the same size as a normal red corpuscle with a small, round, deeply
staining nucleus. Free nuclei may be found. The colorless corpuscles are,
at first, increased in number. There is a moderate leucocytosis, the differen-
tial count showing an increase in the multinuclear neutrophiles with a dimi-
nution in the small mononuclear elements. During recovery the leucocytosis
diminishes. The color index is low, as the haemoglobin regenerates more slowly
and the corpuscles are smaller and lighter.
The reduction in haemoglobin is always proportionately greater than that
in the corpuscles.
In some instances a rapidly fatal anemia may follow a single severe
hemorrhage, as in post-partum cases, or repeated small hemorrhages, as in
purpura. Here the appearances of the red corpuscles are much the same,
except in the total absence of nucleated red corpuscles.
The leucocytes in these cases are usually reduced in number; the poly-
720
DISEASES OF THE BLOOD AND DUCTLESS GLANDS.
nuclear elements are present in a relatively diminished proportion, while the
small mononiiclear forms are numerous. Post mortem there is a total absence
of any regenerative activity on the part of the bone-marrow.
The above description is of the blood changes after one severe haemorrhage.
In the case of repeated haemorrhages the picture depends upon the interval
APRIL. 1 MAY. ! JUNE. 1 JULY.
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BLACK, RED COF?PUSCLES.
RED, HAEMOGLOBIN,
MEAN NORM,
NUMBER OF
WHITE
CORPUSCLES
BLUE, COLOJ?LeSS CORPUSCLES.
Chart XVI. — Illustrates the RAPmiTv with which Ax^mia is Produced in Purpura
HEMORRHAGICA AXD THE GRADUAL ReCOVERT.
between the losses of blood: if long enough to allow complete regeneration
each time the total amount of blood lost may be excessive and yet the patient
recover rapidly after the last as in a case of phthisis mentioned by Ehrlich
who lost by h^emoptj'sis twenty kilogrammes of blood in six and a half months.
If, however, the intervals are so short that recovery from each is not
possible there soon occurs a chronic anaemia with very tardy regeneration; a
hydrgemic plasma, low color index, and l}Tnphoc}i:osis.
( 2 ) Anaemia is frequently produced by long-continued drain on the albn-
minous materials of the blood, as in chronic suppuration and Bright^s disease.
Prolonged lactation acts in the same way. Eapidly growing tumors may
cause a profound anaemia, as in gastric cancer. The characters of the blood
here may be much the same as iu the acute cases. Usually the poikilocytosis
is more marked ; in severe cases it- may be excessive. The presence, however,
ANEMIA. 721
of the very large corpuscles, such as one sees in pernicious angemia, is not
noted, the average size appearing to be rather smaller than normal.
Nucleated red corpuscles are usually scanty. In long-continued chronic
secondary anaemias occasional larger nucleated red corpuscles may be seen,
bodies with larger palely staining nuclei; in some of these cells karyokinetic
figures occur. Nucleated red corpuscles with fragmentary nuclei may also
be seen.
The leucocytes may be increased in number, though in some severe chronic
cases there may be a diminution.
(3) Anaemia from Inanition. — This may be brought about by defective
food supply, or by conditions which interfere with the proper reception and
preparation of the food, as in cancer of the oesophagus and chronic dyspepsia.
The reduction of the blood mass may be extreme, but the plasma suffers pro-
portionately more than the corpuscles, which, even in the wasting of cancer
of the oesophagus, may not be reduced more than one-half or three-fourths.
The reduction in the plasma may be so great that the corpuscles show a
relative increase.
(4) Toxic anaemia is induced by the action of certain poisons on the
blood, such as lead, mercury, and arsenic, among inorganic substances, and
the virus of syphilis and malaria among organic poisons. They act either
by directly destroying the red blood-corpuscles, as in malaria, or by increas-
ing the rate of ordinary consumption. The anaemia of pyrexia may in part
be due to a toxic action, but is also caused in part by the disturbance of
digestion and interference with the function of the blood-making organs.
Pkimaey or Essential Anemia.
1. Chlorosis.
Definition. — An anaemia of unknown cause, occurring in young girls, char-
acterized by a marked relative diminution of the haemoglobin.
Etiology. — It is a disease of girls, more often of blondes than of brunettes.
It is doubtful if males are ever affected. I have never seen true chlorosis in
a boy. The age of onset is between the fourteenth and seventeenth years;
under the age of twelve cases are rare. Eecurrences, which are common, may
extend into the third decade. Of the essential cause of the disease we know
nothing. There exists a lowered energy in the blood-making organs, asso-
ciated in some obscure way with the evolution of the sexual apparatus in
women. Hereditary influences, particularly chlorosis and tuberculosis, play a
part in some cases. Sometimes, as Virchow pointed out, the condition exists
with a defective development (hypoplasia) of the circulatory and generative
organs.
The disease is most common among the ill-fed, overworked girls of large
towns, who are confined all day in close, badly lighted rooms, or have to do
much stair-climbing. Cases occur, however, under the most favorable con-
ditions of life, but not often in country-bred girls, as Maudlin sings in the
Compleat Angler. Lack of proper exercise and of fresh air, and the use of
improper food are important factors. Emotional and nervous disturbances
may be prominent — so prominent that certain writers have regarded the dis-
ease as a neurosis. De Sauvages speaks of a chlorose par amour. Newly
47
722 DISEASES OF THE BLOOD AND DUCTLESS GLANDS.
arrived Irish girls were very prone to the disease in Montreal. The " corset
and chlorosis " expresses 0. Eosenbach's opinion. Menstrual disturbances are
not uncommon, but are probably a sequence, not a cause, of chlorosis. Sir
Andrew Clark believed that constipation plays an important role, and that
the condition is in reality a coprcemia due to the absorption of poisons — leuco-
maines and ptomaines — from the large bowel, a view which does not seem
very reasonable, considering the great frequency of constipation both in
women and in men.
Symptoms. — (a) General. — The symptoms of chlorosis are those of
anaemia. The subcutaneous fat is well retained or even increased in amount.
The complexion is peculiar; neither the blanched aspect of haemorrhage nor
the muddy pallor of grave anaemia, but a curious yellow-green tinge, which
has given to the disease its name, and its popular designation, the green sick-
ness. Occasionally the skin shows areas of pigmentation, particularly about
the joints. In cases of moderate grade the color may be deceptive, as the
cheeks have a reddish tint, particularly on exertion (chlorosis rubra). The
subjects complain of breathlessness and palpitation, and there may be a tend-
ency to fainting — symptoms which often lead to the suspicion of heart or
lung disease. Puffiness of the face and swelling of the ankles may suggest
nephritis. The disposition often changes, and the girl becomes low-spirited
and irritable. The eyes have a peculiar brilliancy and the sclerotics are of a
bluish color.
(&) Special Features. — Blood. — The drop as expressed looks pale.
Johann Duncan, in 1867, first called attention to the fact that the essential
feature was not a great reduction in the number of the corpuscles, but a
quantitative change in the haemoglobin. The corpuscles themselves look pale.
In 63 consecutive cases examined at my clinic by Thayer, the average num-
ber per cubic millimetre of the red blood-corpuscles was 4,096,544, or over
80 per cent, whereas the percentage of haemoglobin for the total number was
42.3 per cent. The accompanying chart illustrates well these striking differ-
ences. There may, however, be well-marked actual anemia. The lowest blood-
count in the series of cases referred to above was 1,933,000. There may be
all the physical characteristics and symptoms of a profound anaemia with the
number of the blood-corpuscles nearly at the normal standard. Thus in one
instance the globular richness was over 85 per cent, with the haemoglobin
about 35. No other form of anaemia presents this feature, at least with the
same constancy and in the same degree. The importance of the reduction in
the haemoglobin depends upon the fact that it is the iron-containing elements
of the blood with which in respiration the oxygen enters into combination.
This marked diminution in the iron has also been determined by chemical
analysis of the blood. The microscopical characteristics of the blood are as
follows : In severe cases the corpuscles may be extremely irregular in size and
shape — poikilocytosis, which may occasionally be as marked as in some cases
of pernicious anaemia. The large forms of red blood-cells are not as com-
mon, and the average size is stated to be below normal. The color of the
corpuscles is noticeably pale and the deficiency may be seen either in indi-
vidual corpuscles or in the blood mixture prepared for counting. Nucleated
red corpuscles (normoblasts) are not very uncommon, and may vary greatly
in numbers in the same case at different periods. The leucocytes may show
ANEMIA.
723
a slight increase; the average in the 63 cases above referred to was 8,467 per
cubic millimetre.
(c) Gasteo-intestinal Symptoms. — The appetite is capricious, and pa-
tients often have a longing for unusual articles, particularly acids. In some
instances they eat all sorts of indigestible things, such as chalk or even earth.
Superacidity of the gastric juice is commonly associated with chlorosis. In
19 out of 21 cases in Eiegel's clinic this condition was found to exist. In
the other two instances the acidity was normal or a trifle increased. Distress
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WHITE
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BLACK, RED CORPUSCLES.
RED, HAEMOGLOBIN.
Chart XVII. — Chlorosis.
BLUE, COLORLESS CORPUSCLES,
after eating and even cardialgic attacks may be associated with it. Con-
stipation is a common symptom, and, as already mentioned, has been regarded
as an important element in causing the disease. A majority of chlorotic girls
who wear corsets have gastroptosis, and on inflation the stomach will be found
vertically placed; sometimes the organ is very much dilated. The motor
power is usually well retained. Enteroptosis with palpable right kidney is
not uncommon.
724 DISEASES OF THE BLOOD AND DUCTLESS GLANDS.
(d) CiECULATORY SYMPTOMS. — Palpitation of the heart occurs on exer-
tion, and may be the most distressing s}Taptom of which the patient com-
plains. Percussion may show slight increase in the transverse dulness. A
systolic murmur is heard at the apex or at the base; more commonly at the
latter, but in extreme cases at both. A diastolic murmur is rarely heard.
The systolic murmur is usually loudest in the second left intercostal space,
where there is sometimes a distinct pulsation. The exact mode of production
is still in dispute. Balfour holds that it is produced at the mitral orifice by
relative insufficiency of the valves in the dilated condition of the ventricle.
On the right side of the neck over the jugular vein a continuous murmur
may be heard, the hruit de diahJe. or humming-top murmur.
The pulse is usually full and soft. Visible impulse is present in the veins
of the neck, as noted by Lancisi. Pulsation in the peripheral veins is some-
times seen. Thrombosis in the veins may occur, most commonly in the
femoral, but in other instances in the cerebral sinuses there may be multiple
thrombi. In 86 cases the veins of the legs were affected in 48, the cerebral
sinuses in 29 (Lichtenstern). The chief danger in thrombosis of the extremi-
ties is pulmonary embolism, which occurred in 13 of 52 cases collected by
Welch.
As in all forms of essential antemia, fever is not uncommon. Chlorotic
patients suffer frequently from headache and neuralgia, which may be parox-
ysmal. The hands and feet are often cold. Dermatographia is common.
Hysterical manifestations are not infrequent. Menstrual disturbances are very
common — amenorrhoea or dysmenorrhosa. With the improvement in the blood
condition this function is usually restored.
Diagnosis. — The green sickness, as it is sometimes called, is in many in-
stances recognized at a glance. The well-nourished condition of the girl, the
peculiar complexion, which is most marked in brunettes, and the white or
bluish sclerotics are very characteristic. A special danger exists in mistak-
ing the apparent anasmia of the early stage of pulmonary tuberculosis for
chlorosis. Mistakes of this sort may often be avoided by the very simple
test furnished by allowing a drop of blood to fall on a white towel or a piece
of blotting paper — a deficiency in hgemoglobin is readily appreciated. The
palpitation of the heart and shortness of breath frequently suggest heart-dis-
ease, and the oedema of the feet and general pallor cause the cases to be mis-
taken for Bright's disease. In the great majority of cases the characters of
the blood readily separate chlorosis from other forms of angemia.
2. Idiopathic or Progressive Pernicious AncBmia.
The disease was first clearly described by Addison, who called it idio-
pathic ansmia. Charming and Gusserow described the cases occurring post
partum, but to Biermer we owe a revival of interest in the subject.
Etiology. — The existence of a separate disease worthy of the term pro-
gressive pernicious anamia has been doubted, but there are very many
cases in which, as Addison says, there exist none of the usual causes or
concomitants of anemia. Clinically there are several different groups which
present the characters of a progressive and pernicious anaemia and are etiolog-
ically different. Thus, a fatal anaemia may be due to the presence of para-
ANEMIA. 725
sites, or may follow haemorrhage, or be associated with chronic atrophy of the
stomach; but when we have excluded all these causes there remains a group
which, in the words of Addison, is characterized by a " general anaemia
occurring without any discoverable cause whatever, cases in which there had
been no previous loss of blood, no exhausting diarrhoea, no chlorosis, no
purpura, no renal, splenic, miasmatic, glandular, strumous, or malignant
disease."
William Hunter considers that the idiopathic anaemia described by Addi-
son and the progressive pernicious anaemia of Biermer are different affections.
That described by Addison is a distinct disease, while that described by Bier-
mer is " a frequently recurring group of symptoms met with in very different
conditions of disease." Hunter holds that there are two important factors
in the disease, (a) haemolysis and (&) a chronic septic infection often asso-
ciated with a specific glossitis, and oral, gastric, and intestinal sepsis.
Idiopathic anaemia is widely distributed. It is of frequent occurrence
in the Swiss cantons, and it is common in the United States. It affects mid-
dle-aged persons, but instances in children have been described. Of the 81
cases in my hospital series 36 were above fifty years of age; only 1 was under
twenty, Griffith mentions about 10 cases occurring under twelve years of
age. The youngest patient I have seen was a boy of ten. Males are more
frequently affected than females. Of 550 cases collected by Colman, 323 were
in men and 227 in women, Sinkler and Eshner record 3 cases in one family,
the father and two girls.
With the following conditions may be associated a profound anaemia not
always to be distinguished clinically from Addison's idiopathic form :
(a) Pregnancy and Parturition. — The symptoms may occur during preg-
nancy, as in 19 of 29 cases of this group in Eichhorst's table. More com-
monly, in my experience, the condition has been post partum.
(&) Atrophy of the Stomach. — This condition, early recognized by Flint
and Fenwick, may certainly cause a progressive pernicious anaemia. By mod-
ern methods it may now be possible to exclude this extreme gastric atrophy.
(c) Parasites. — The most severe form may be due to the presence of para-
sites, and the accounts of cases depending upon the anchylostoma and the
bothriocephalus describe a progressive and often pernicious anaemia.
After the exclusion of these forms there remain a large proportion, which
correspond to Addison's description. The researches of Quincke and his stu-
dent Peters showed that there was an enormous increase in the iron in the
liver, and they suggested that the affection was probably due to increased
hemolysis. This has been strongly supported by the extensive observations
of Hunter, who has also shown that the urine excreted is darker in color and
contains pathological urobilin. The lemon tint of the skin or the actual
jaundice is attributed, on this view, to an overproduction. To explain the
haemolysis, it has been thought that in the condition of faulty gastro-intestinal
digestion, which is so commonly associated with these cases, poisonous mate-
rials are developed, which when absorbed cause destruction of the corpuscles.
Certainly the case for haemolysis is very strong, and is supported by the experi-
mental work of Bunting, who has been able to produce in animals a condition
the counterpart of pernicious anaemia in man.
Stockman suggests that repeated small capillary haemorrhages — chiefly in-
726 DISEASES OF THE BLOOD AND DUCTLESS GLANDS.
ternal — ^play an important role in the causation of the disease, which also
explains, he holds, the existence of a great excess of iron in the liver.
On the other hand, F. P. Henry, Stephen Mackenzie, Eindfleisch, and other
authorities incline to the belief that the essence of the disease is in defective
haemogenesis, in consequence of which the red blood-corpuscles are abnor-
mally vulnerable.
Morbid Anatomy. — The body is rarely emaciated. A lemon tint of the
skin is present in a majority of the cases. The muscles often are intensely
red in color, like horse-flesh, while the fat is light yellow. Haemorrhages are
common on the skiu and serous surfaces. The heart is usually large, flabby,
and empty. In one instance I obtained only 2 drachms of blood from the
right heart, and between 3 and 4 from the left. The muscle substance of the
heart is intensely fatty, and of a pale, light-yellow color. In no affection do
we see more extreme fatty degeneration. The lungs show no special changes.
The stomach in many instances is normal, but in some cases of fatal anaemia
the mucosa has been extensively atrophied. In the case described by Henry
and myself the mucous membrane had a smooth, cuticular appearance, and
there was complete atrophy of the secreting tubules. The liver may be enlarged
and fatty. In most of my autopsies it was normal in size, but usually fatty.
The iron is in excess, a striking contrast to the condition in cases of secondary
anemia. It is deposited in the outer and middle zones of the lobules, and in
two specimens, which I examined, seemed to have such a distribution that the
bile capillaries were distinctly outlined. This, Hunter states, is a special and
characteristic lesion, possibly peculiar to pernicious anaemia.
The spleen shows no important changes. In one of Palmer Howard's
cases the organ weighed only 1 ounce and 5 drachms. The iron pigment is
usually in excess. The lymph-glands may be of a deep red color. The amount
of iron pigment is increased in the kidneys, chiefly in the convoluted tubules.
The bone-marrow is usually red, lymphoid in character, showing great num-
bers of nucleated red corpuscles, especially the larger forms called by Ehrlich
gigantoblasts. Cases in which the bone-marrow shows no signs of activity
have been described as aplastic ancemia. Lichtheim and others have found
sclerosis in the posterior columns of the cord.
Symptoms. — The patient may have been in previous good health, but in
many cases there is a history of gastro-intestinal disturbance, mental shock,
or worry. The description given by Addison presents the chief features of the
disease in a masterly way. " It makes its approach in so slow and insidious
a manner that the patient can hardly flx a date to the earliest feeling of that
languor which is shortly to become so extreme. The countenance gets pale,
the whites of the eyes become pearly, the general frame flabby rather than
wasted, the pulse perhaps large, but remarkably soft and compressible, and
occasionally with a slight jerk, especially under the slightest excitement.
There is an increasing indisposition to exertion, with an uncomfortable feeling
of faintness or breathlessness in attempting it; the heart is readily made to
palpitate; the whole surface of the body presents a blanched, smooth, and
waxy appearance; the lips, gums, and tongue seem bloodless, the flabbiness
of the solids increases, the appetite fails, extreme languor and faintness super-
vene, breathlessness and palpitations are produced by the most trifling exertion
or emotion; some slight oedema is probably perceived about the ankles; the
ANEMIA.
72T
debility becomes extreme — the patient can no longer rise from bed; the mind
occasionally wanders; he falls into a prostrate and half-torpid state, and at
length expires; nevertheless, to the very last, and after a. sickness of several
months' duration, the bulkiness of the general frame and the amount of obes-
ity often present a most striking contrast to the failure and exhaustion observ-
able in every other respect."
The Blood. — The red corpuscles may fall to one-fifth or less of the nor-
mal number. The average count in my 81 (in 103 admissions) hospital cases
was 1,575,000 per cubic millimetre — ^that is, in 81 per cent of the cases under
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WHITE
CORPUSCLES
BLACK, RED CORPUSCLES.
RED, HAEMOGLOBIN.
BLUE, COLORLESS CORPUSCLES.
Chart XVIII. — Pernicious An-smia.
2,000,000 and in 12 per cent under 1,000,000 cells — and the haemoglobin was
about 30 per cent. The haemoglobin is relatively increased, so that the indi-
vidual globular richness is plus, a condition exactly the opposite to that which
occurs in chlorosis and the secondary anemia, in which the corpuscular rich-
728 DISEASES OF THE BLOOD AND DUCTLESS GLANDS.
ness in coloring matter is minus. The relative increase in the haemoglobin is
probably associated with the average increase in the size of the red blood-cor-
puscles. Chart XVIII, page 727, illustrates these points. Microscopically the
red blood-corpuscles present a great variation in size, and there can be seen
large giant forms, megaloc3''tes, which are often ovoid in form, measuring
8, 11, or even 15 /a in diameter — a circumstance which Henry regards as indi-
cating a reversion to a lower type. Laache thinks these pathognomonic, and
they certainly form a constant feature. There are also small round cells,
microcytes, from 2 to 6 ^i in diameter, and of a deep red color. The corpus-
ces show a remarkable irregularity in form; they are elongated and rodlike
or pyriform; one end of a corpuscle may retain its shape while the other is
narrow and extended. To this condition of irregularity Quincke gave the
name poikilocytosis.
Nucleated red blood-corpuscles are almost always present, as pointed out
by Ehrlich. It may require a long search to find them. There are two tj'pes,
normoblasts and megaloblasts, which Ehrlich regards as almost distinctive of
this anaemia. There are frequently forms intermediate between these two
groups which often have irregular nuclei. A relatively large number of
megaloblasts usually indicates a grave outlook. Though these large forms are
most characteristic, occasionally forms closely similar to them may be found
in the graver secondary anaemias — e. g., bothriocephalus anaemia, anchylosto-
miasis — and in leukaemia. Karyokinetic figures may be seen in these bodies.
Red corpuscles with fragmenting nuclei are common in pernicious anaemia.
Blood crises were first described under this name by v. Noorden. He con-
sidered the phenomenon one of active blood regeneration, causing the appear-
ance in the peripheral blood of large numbers of nucleated reds; which remain
for a few days, and are followed by a decided gain in the blood-count. This
may be true in secondary anaemias, but in pernicious anaemia they are often
part of the terminal picture with declining count of red corpuscles and leuco-
cytes, and the presence of large numbers of nucleated reds which may continue
even for nineteen weeks, as if the marrow were making convulsive but fruitless
efforts to restore the blood. There were 20 crises in 13 of my 81 cases, and in
5 they were terminal events. Three-fourths of these crises were megaloblastic
in character, in the others the cells were chiefly normoblasts. In the highest
crisis there were 14,388 normoblasts, 460 intermediates, and 138 megaloblasts
per cubic millimetre. Bensangon and Labbe mention a crisis with 10,000
normoblasts and 960 megaloblasts per cubic millimetre (the intermediates
were probably counted with the latter). Only 5 of the 20 crises were followed
by a real gain in the count of red cells, and these were of normoblastic type.
The leucocjdies are generally normal or diminished in number, even to 500
per cubic millimetre ; and a marked relative increase in the small mononuclear
forms — in one of my cases even 79 per cent, yet with absolute number normal
— ^with a diminution in the pohmuclear leucocytes, is often noted. ]\Iyeloc}i:es
are usually found, and in one of my cases were 8 per cent. The blood-plates are
either absent or very scanty.
The cardio-vascular symptoms are important and are noted in the de-
scription given above. Haemic murmurs are usually present. The larger
arteries pulsate visibly and the throbbing in them may be distressing to the
patient. The pulse is full and frequently suggests the water-hammer beat of
ANJEMIA. 729
aortic insufficiency. The capillary pulse is frequently to be seen. The super-
ficial veins are often prominent, and I have seen well-marked pulsation in
them. Haemorrhages occurred, either in the skin or from the mucous sur-
faces, in 12 cases of my series. Eetinal haemorrhages are common. There are
rarely symptoms in the respiratory organs.
Gastro-intestinal symptoms, such as dyspepsia, nausea, and vomiting, may
be present throughout the disease. Diarrhoea is not infrequent. The urine is
usually of a low specific gravity and sometimes pale, but in other instances it is
of a deep sherry color, shown by Hunter and Mott to be due to great excess
of urobilin. Fever was present in three-fourths of my cases.
The slcin has most frequently a lemon- tint, sometimes positively icteroid;
in a few cases there is pallor without any change in color, while in a third
group the skin is pigmented, so that Addison's disease is suspected. This
occurs in a few instances in which arsenic has not been given; as a rule it
follows the administration of this drug. The pigmentation may be patchy
and associated with areas of leucoderma. The nervous symptoms are of great
interest. Extensive changes may be present in the cord without any symp-
toms during life. In a majority of the cases the numbness comes on in the
legs and feet, less often in the hands, and in a few instances there is pain of
great severity. Gradually the signs of postero-lateral sclerosis become well
marked. In a third group, described by Eisien Eussell, Batten, and Collier,
the nervous symptoms — indicating a postero-lateral sclerosis — come first and
the anaemia follows ; but the cases have not always the features of the progres-
sive pernicious disease.
Diagnosis. — The disease is not often recognized by the general practi-
tioner. The 1-emon-yellow tint of the skin leads to the diagnosis of jaundice;
the pigmentation suggests Addison s disease; the anaemia, puffy face, swollen
ankles, and albumin in the urine. Bright' s disease ; the shortness of breath and
palpitation, heart-disease; the pallor and gastric symptoms, cancer of the
stomach. The retention of fat, the insidious onset, the absence of signs of local
disease, and the blood features already discussed are the most important diag-
nostic points. From cancer of the stomach it is distinguished by (1) the
absence of wasting; (2) the high-color index of the blood and the lower cor-
puscular count, reaching frequently below one million per cubic millimetre;
(3) the absence of the fairly characteristic reactions of the stomach contents;
and (4) the marked improvement in the first attacks with rest, fresh air,
diet, and arsenic.
Prognosis. — In the true Addisonian cases the ultimate outlook is bad; of
late years the proportion of cases of temporary recovery has increased. Of the
81 cases from my wards, death occurred in 27 while under observation. Counts
taken in 18 of the fatal cases on the day of death were all below 700,000 red
cells per cmm. The average duration of these was one year. One patient recov-
ered completely. He was admitted in 1890 with a history of one year, was dis-
charged well, and returned in 1896 with cancer of the stomach. One patient
is in good health six years and another four years after the onset. In Pye-
Smith's article in the Guy's Hospital Eeports he mentions 20 cases of recovery.
Colman, in a recent article, states that one of these cases treated with arsenic
in 1880 was alive and well in March, 1900. The history is usually not one of
progressive advance but of alternate periods of gain and loss. In my series
730 DISEASES OF THE BLOOD AND DUCTLESS GLANDS.
a red coimt below one million has been a bad omen. The presence of many
megaloblasts is unfavorable. They were relatively eleven times more numerous
in the fatal cases of my series than in those that recovered. That a large rela-
tive percentage of small mononuclears was of bad import is not supported by
my cases. Those that recovered had a slightly higher average percentage than
the fatal cases. The blood crises are usually of ill omen. Patients who do
not take arsenic well usually do badly. Gastro-intestinal disturbances are
serious. There are remarkable acute cases which may prove fatal withia ten
days, as in a patient I saw with Finley, of Montreal.
Treatment of Anaemia. — Secoxdaey Ax^mia. — The traumatic cases do
best, and with plenty of good food and fresh air the blood is readily restored.
The extraordinary rapidit}- with which the normal percentage of red blood-
corpuscles is reached without any medication whatever is an important lesson.
The cause of the hjemorrhage should be sought and the necessary indica-
tions met. The large group depending on the drain on the albuminous mate-
rials of the blood, as in Bright' s disease, suppuration, and fever, is difficult to
treat successfully, and so long as the cause keeps up it is impossible to restore
the normal blood condition. The anaemia of inanition requires plenty of
nourishing food. When dependent on organic changes in the gastro-intestinal
mucosa not much can be expected from either food or medicine. In the toxic
cases due to mercury and lead, the poison must be eliminated and a nutritious
diet given with full doses of iron. In a great majority of these cases there is
deficient blood formation, and the indications are briefly three: plenty of
food, an open-air life, and iron. As a rule it makes but little difference what
form of the drug is administered.
Chloeosis. — The treatment of chlorosis affords one of the most brilliant
instan-ces — of which we have but three or four — of the specific action of a rem-
edy. Apart from the action of quinine in malarial fever, and of mercury and
iodide of potassium in s}"philis, there is no other drug the beneficial effects of
which we can trace with the accuracy of a scientific experiment. It is a minor
matter how the iron cures chlorosis. In a week we give to a case as much iron
as is contained in the entire blood, as even in the worst case of chlorosis there
is rarely a deficit of more than 2 grammes of this metal. Iron is present in
the feeces of chlorotic patients before they are placed upon any treatment,
so that the disease does not result from any deficiency of available iron in the
food. Bunge believes that it is the sulphur which interferes with the digestion
and assimilation of this natural iron. The sulphides are produced in the
process of fermentation and decomposition in the faeces, and interfere with
the assimilation of the normal iron contained in the food. By the adminis-
tration of an inorganic preparation of iron, with which these sulphides unite,
the natural organic combmations in the food are spared.
In stud5fing charts of chlorosis, it is seen that there is an increase in the
red blood-corpuscles under the influence of the iron, and in some instances
the globular richness rises above normal. The increase in the hsemoglobin is
slower and the maximum percentage may not be reached for a long time. I
have for years in the treatment of chlorosis used with the greatest success
Blaud's pills, made and given according to the formula in JTiemejo-'s text-book,
in which each pill contains 2 grains of the sulphate of iron. During the first
week one pill is given three times a day; in the second week, two pills; in
LEUKEMIA. 731
the third week, three pills, three times a day. This dose should be continued
for four or five weeks at least before reduction. An important feature in the
treatment is to persist in the use of the iron for at least three months, and, if
necessary, subsequently to resume it in smaller doses, as recurrences are so
common. The diet should consist of good, easily digested food. Special care
should be directed to the bowels, and if constipation is present a saline purge
should be given each morning. Such stress did Sir Andrew Clark lay on the
importance of constipation in chlorosis, that he stated that if limited to the
choice of one drug in the treatment of the disease he would choose a purga-
tive. In many instances the dyspeptic symptoms may be relieved by alkalies.
Dilute hydrochloric acid, manganese, phosphorus, and oxygen have been recom-
mended. Eest in bed is important in severe cases.
Treatment of Pernicious Anemia. — There are five essentials : first, a
diagnosis; secondly, rest in bed for weeks or even months, if possible (thirdly)
in the open air; fourthly, all the good food the patient can take; the outlook
depends on the stomach ; fifthly, arsenic ; Fowler's solution in increasing doses,
beginning with Til, iii or v three times a day, and increasing th, i each week until
the patient takes TTl, xv or xx three times a day. Other forms of arsenic may be
tried, as the sodium cacodylate or the atoxyl hypodermically. Accessories are
oil inunctions; bone-marrow, which has the merit of a recommendation by
Galen; in some cases iron seems to do good. Care should be taken of the
mouth and teeth. After recovery the patient should be told to watch the
earliest indications of return of the trouble and at once resume the arsenic.
II. LEUKiEMIA.
Definition. — An affection characterized by persistent increase in the white
blood-corpuscles, associated with changes, either alone or together, in the
spleen, lymphatic glands, or bone-marrow.
The disease was described almost simultaneously by Yirchow and by Ben-
nett, who gave to it the name leucocythsemia. It is ordinarily seen in two
main types, though combinations and variations may occur:
(1) Spleno-medullary leukaemia, in which the changes are especially
localized in the spleen and the bone-marrow, while the blood shows a great
increase in elements which are derived especially from the latter tissue, a con-
dition which Miiller has termed " myelsemia." Ehrlich prefers to call this
type of the disease " myelogenous leukaemia," believing the part played by
the spleen in the process to be purely passive.
(2) Lymphatic leukaemia, in which the changes are chiefly localized in
the l3rmphatic apparatus, the blood showing an especial increase in those ele-
ments derived from the lymph-glands.
Etiology. — We know nothing of the conditions under which the disease
arises. It is not uncommon in America. There have been 37 cases in my
wards in fifteen years, of which 24 were of the spleno-myelogenous and 13
of the lymphatic type. There were 21 males and 16 females. Four were
colored. There were 24 below the age of forty years. The disease is most
common in the middle period of life. The youngest of my patients was a
child of eight months, and cases are on record of the disease as early as the
eighth or tenth week. It may occur as late as the seventieth year. Males
732 DISEASES OF THE BLOOD AND DUCTLESS GLANDS.
are more prone to the affection than females. Birch-Hirschfeld states that
of 200 cases collected from the literature, 135 were males and 65 females.
A tendency to haemorrhage has been noted in many cases, and some of the
patients have suffered repeatedly from nose-bleeding. In women the disease
is most common at the climacteric. There are instances in which it has
occurred during pregnancy. The case described by J. Chalmers Cameron, of
Montreal, is in this respect remarkable, as the patient passed through three
pregnancies, bearing on each occasion non-leuksemic children. The case is
interesting, too, as showing the hereditary character of the affection, as the
grandmother and mother, as well as a brother, suffered from symptoms
strongly suggestive of leuksemia. One of the patient's children had leukaemia
before the mother showed any signs, and a second died of the disease. This
patient gradually recovered from the third confinement, and the red blood-
corpuscles had risen to 4,000,000 per cubic millimetre, and the ratio of white
to red was 1 to 200. Sanger has reported a case in which a healthy mother
bore a leukaemic child.
Malaria is believed by some to be an etiological factor. Of 150 cases
analyzed by Gowers, there was a history of malaria in 30 ; of my hospital cases
comparatively few gave a history of it. The disease has followed injury or
a blow. The lower animals are subject to the affection, and cases have been
described in horses, dogs, oxen, cats, swine, and mice.
Morbid Anatomy. — The wasting may be extreme, and dropsy is sometimes
present. There is in many cases a remarkable condition of polyasmia; the
heart and veins are distended with large blood-clots. In Case XI of my
series the weight of blood in the heart chambers alone was 620 grammes.
There may be remarkable distention of the portal, cerebral, pulmonary, and
subcutaneous veins. The blood is usually clotted, and the enormous increase
in the leucocytes gives a pus-like appearance to the coagula, so that it has
happened more than once, as in Virchow's memorable case, that on opening
the right auricle the observer at first thought he had cut into an abscess. The
coagula have a peculiar greenish color, somewhat like the fat of a turtle. Some-
times this is so intense as to suggest the color of chloroma, described later.
The alkalinity of the blood is diminished. The fibrin is increased. The
character of the corpuscles will be described under the symptoms. Charcot's
octahedral crystals may separate from the blood after death. The specific
gravity of the blood is somewhat lowered. There may be pericardial ecchy-
moses.
In the spleno-meduUary form the spleen is greatly enlarged. Strong adhe-
sions may unite it to the abdominal wall, the diaphragm, or the stomach.
The capsule may be thickened; the vessels at the hilus are enlarged. The
weight may range from 2 to 18 pounds. The organ is in a condition of chronic
hyperplasia. It cuts with resistance, has a uniformly reddish-brown color,
and the Malpighian bodies are invisible. Grayish-white, circumscribed,
lymphoid tumors may occur throughout the organ, contrasting strongly with
the reddish-brown matrix. In the early stage the swollen spleen pulp is softer,
and it is stated that rupture has occurred from the intense hypersemia.
There is an extraordinary hyperplasia of the red marrow. Instead of a fatty
tissue, the medulla of the long bones may resemble the consistent matter which
forms the core of an abscess, or it may be dark brown in color. There may be
LEUKEMIA. 733
haemorrhagic infarctions. There may be much expansion of the shell of
bone, and localized swellings which are tender and may even yield to firm
pressure. Histologically, there are found in the medulla large numbers of
nucleated red corpuscles in all stages of development, numerous cells with
eosinophilic granules, both small polynuclear forms and large almost giant
mononuclear elements. There are also many large cells with single large
nuclei and neutrophilic granules — the cellules medullaires of Cornil — the
myelocytes which are found in the blood. Great numbers of polynuclear leu-
cocytes are also present, as well as a certain number of small mononuclear ele-
ments.
In the lymphatic forms of the disease there is a general lymphatic en-
largement, which is usually associated with a certain amount of enlargement
•of the spleen. In the cases of lymphatic leukaemia the cervical, axillary,
mesenteric, and inguinal groups may be much enlarged, but the glands are
usually soft, isolated, and movable. They may vary considerably in size during
the course of the disease. In acute cases the tonsils and the lymph follicles
of the tongue, pharynx, and mouth may be enlarged.
In some instances there are leukaemic enlargements in the solitary and
agminated glands of Peyer. In a case of Willcocks' there were growths on
the surface of the stomach and gastro-splenie omentum. The thymus is rarely
involved, though it has been enlarged in some of the acute cases. The bone-
marrow in these cases may be replaced by a lymphoid tissue. Nucleated red
■corpuscles and the normal granular marrow elements may be greatly reduced
in number.
The liver may be enlarged, and in a case described by Welch it weighed
•over 13 pounds. The enlargement is usually due to a diffuse leukaemic infiltra-
tion. The columns of liver cells are widely separated by leucocytes, which are
partly within and partly outside the lobular capillaries. There may be definite
leukaemic growths.
There are rarely changes of importance in the lungs. The kidneys are
•often enlarged and pale, the capillaries may be distended with leucocytes, and
leuksemic tumors may occur. The skin may be involved, as in a case described
by Kaposi.
Leukaemic tumors in the organs are not common. In 159 cases collected
by Gowers there were only 13 instances of leukaemic nodules in the liver and
10 in the kidneys. These new growths probably develop from leucocytes which
leave the capillaries. Bizzozero has shown that the cells which compose them
are in active fission.
Symptoms. — The onset is insidious, and, as a rule, the patient seeks advice
for progressive enlargement of the abdomen and shortness of breath, or for
the enlarged glands or the pallor, palpitation, and other symptoms of anae-
mia. Bleeding at the nose is common. Gastro-intestinal symptoms may precede
the onset. Occasionally the first symptoms are of a very serious nature. In
•one of the cases of my series the boy played lacrosse two days before the onset
•of the final haematemesis ; and in another case a girl, who had, it was sup-
posed, only a slight chlorosis, died of fatal haemorrhage from the stomach -
"before any suspicion had been aroused as to the true condition.
Anaemia is not a necessary accompaniment of all stages of the disease; the
subjects may look very healthy and well.
734 DISEASES OF THE BLOOD AND DUCTLESS GLANDS.
As has been stated, the disease is most commonly seen in two main types,
though combinations may occnr.
(1) Spleno-medullaey Leue^mia.— This is much the commonest type
of the disease. The gradual increase in the volume of the spleen is the most
prominent symptom in a majority of the cases. Pain and tenderness are com-
mon, though the progressive enlargement may be painless. A creakii]^ fremi-
tus may be felt on palpation. The enlarged organ extends downward to the
right, and may be felt just at the costal edge, or when large it may extend as
far over as the navel. In many cases it occupies fully one-half of the abdo-
men, reaching to the pubes below and extending beyond the middle line. As
a rule, the edge, in some the notch or notches, can be felt distinctly. Its size
varies greatly from time to time. It may be perceptibly larger after meals.
A haemorrhage or free diarrhoea may reduce the size. The pressure of the
enlarged organ may cause distress after eating; in one ease it caused fatal
obstruction of the bowels. A murmur may sometimes be heard over the spleen,
and Gerhardt has described a pulsation in it.
The pulse is usually rapid, soft, compressible, but often full in volume.
There are rarely any cardiac symptoms. The apex beat may be lifted an inter-
space by the enlarged spleen. Toward the close oedema may occur in the
feet or general anasarca. Haemorrhage is common. There may be most
extensive purpura, or hsemorrhagic exudate into pleura or peritonaeum. Epis-
taxis is the most frequent form. Ha3moptysis and haematuria are rare.
Bleeding from the gums may be present. Hamatemesis proved fatal in two
of my eases, and in a third a large cerebral haemorrhage rapidly killed. The
leukemic retinitis is a part of the haemorrhagic manifestations. J. Hughes
Bennett's first leukaemic patient died suddenly, without obvious cause.
Local gangrene may develop, with signs of intense infection and high fever.
There are very few pulmonary symptoms. The shortness of breath is due,
as a rule, to the anaemia. Toward the end there may be oedema of the lungs,
or pneumonia may carry off the patient. The gastro-intestinal symptoms are
rarely absent. ISTausea and vomiting are early features in some cases. Diar-
rhoea may be very troublesome, even fatal. Intestinal haemorrhage is not
common. There may be a dysenteric process in the colon. Jaundice rarely
occurs, though in one case of my series there were recurrent attacks. Ascites
may be a prominent symptom, probably due to the presence of the splenic
tumor. A leuksemic peritonitis also may be present, due to new growths in
the membranes.
The nervous system is not often involved. Facial paralysis has been noted.
Headache, dizziness, and fainting spells are due to anaemia. The patients are
usually tranquil. Coma may follow cerebral haemorrhage.
The special senses are often affected. There is a peculiar retinitis, due
chiefly to the extravasation of blood, but there may be aggregations of leuco-
cytes, forming small leukaemic growths. Optic neuritis is rare. Deafness has
frequently been observed; it may appear early and possibly is due to haemor-
rhage. Features suggestive of Meniere's disease may come on quite suddenly,
due to leukaemic infiltration or haemorrhage into the semi-circular canal.
The urine presents no constant changes. The uric acid excreted is always
in excess.
Priapism is a curious symptom which has been present in a large num-
LEUKEMIA.
735
ber of cases. It may, as in one of our cases, be the first symptom. In one
of my cases it persisted for seven weeks. The cause is not known.
Fever was present in two-thirds of my series. Periods of pyrexia may
alternate with prolonged intervals of freedom. The temperature may range
from 103° to 103°.
1890.
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BLACK, RED CORPUSCLES.
RED, HAEMOGLOBIN.
BLUE, COLORLESS CORPUSCLES.
Chart XIX. — Leuk.^mia.
Blood. — In all forms of the disease the diagnosis must be made by the
examination of the blood, as it alone offers distinctive features.
The most striking change in the more common form, the spleno-myelog-
enous, is the increase in the colorless corpuscles. The average in one of my
736 DISEASES OF THE BLOOD AND DUCTLESS GLANDS.
series was 398,700 per cubic millimetre, and the average ratio to the red cells
was 1 to 10. The proportion may be 1 to 5, or may even reach 1 to 1. There
are instances on record in which the number of leucocytes has exceeded that
of the red corpuscles. The leucocytes may vary greatly within short intervals.
The small mononuclear forms are little if at all increased ; relatively they
are greatly diminished. The eosinophdes are present in normal or increased
relative proportion, so that there is a great total increase, and their presence
is a striking feature in the stained blood-slide. The polynuclear neutrophiles .
may be in normal proportion ; more frequently they are relatively diminished,
and in the later stages they may form but a small proportion of the colorless
elements. Marked differences in size between individual poljoiuclear leucocytes
may be noted; the same is true of the eosinophiles. The most characteristic
features of the blood in this form of leukaemia is the presence of cells which
do not occur in normal blood. They appear to be derived from the marrow,
and are called by Ehrlich myelocytes. They are large mononuclear neutro-
philic cells, which may vary much in size. They comprise about 30 per cent
of the colorless cells. Nicked nuclei are common. Miiller has recently found
many large mononuclear elements with karyokinetic figures in leukaemic blood
and in the marrow. These probably correspond to the myelocytes of Ehrlich
as well as to the " cellules meduUaires " of Cornil. Polynuclear cells with
coarse basophilic granules, " Mastzellen," are always present in this form of
leuksemia in considerable numbers. The granules do not staia in Ehrlich's
triacid mixture, and the cells may be recognized as polynuclear non-granular
elements. These cells, which form only about 0.28 per cent of the leucocytes
of normal blood, may be even more numerous than the eosinophiles.
Nucleated red blood-corpuscles are present in considerable numbers.^
These are usually "normoblasts," but cells with larger paler nuclei, some
showing evidences of mitosis, may be seen. Eed cells with fragmented nuclei
are common, while true megaloblasts may be found. The average number of
red cells in one of my series was 2,850,000 per cubic millimetre. In no case
was the count below two million. The average haemoglobin was 42 per cent.
The blood chart on page 735 is from a case of leukaemia with an enor-
mously enlarged spleen. Among other points about leuksemic blood may be
mentioned the feebleness of the amoeboid movement, as noted by Cavafy,
which may be accounted for by the large number of mononuclear elements
present, as the polynuclear alone are stated to possess this power. The blood-
plates exist in variable numbers; they may be remarkably abundant. The
fibrin network between the corpuscles is usually thick and dense. In blood
slides which are kept for a short time, Charcot's octahedral crystals separate,
and in the blood of leukaemia the haemoglobin shows a remarkable tendency to
crystallize.
2. Lymphatic Leukemia. — This form of leukaemia is rare. There were
13 out of 37 in my hospital series, of which 5 were acute. The superficial
glands are usually most involved, but even when affected it is rare to see such
large bunches as in Hodgkin's disease. External lymph tumors are rare. Lym-
phatic leukaemia is often more rapid and fatal in its course, though chronic
cases may occur. It is more common in young subjects.
The histological characters of the blood in lymphatic leukaemia differ
materially from those in the spleno-medullary form. The increase in the
LEUKEMIA. 737
■colorless elements is never so great as in the preceding form ; a proportion of
1 to 10 would be extreme. The number of both white and red cells showed
great variations in my series. This increase takes place solely in the lympho-
cytes, all other forms of leucocytes being present in greatly diminished rela-
tive proportion. In one of my cases over 99 per cent of all the leucocytes
were lymphocytes. In some cases, as Cabot has pointed out, this increase
takes place largely in the smaller forms, while in others the large lympho-
<3ytes — cells nearly as large as polynuclear leucocytes^predominate. Eosino-
philes and nucleated, red corpuscles are rare. Myelocytes are not present.
Combined forms of leukaemia are not common.
Leukancemia. — This term was used by Leube to describe a condition which
showed features both of leukaemia and severe anaemia. Some of the cases of
acute leukaemia come under this head, but it must be regarded rather as a clin-
ical term than a pathological condition. The symptoms are often suggestive of
an acute infection. The onset may be sudden, and is frequently with severe
tonsillitis, so that the throat condition is the most striking feature. The promi-
nent symptoms are fever, weakness, haemorrhages, extreme pallor, and a rapid
downward course. General glandular enlargement is frequently, although not
constantly present. The liver and spleen are usually enlarged. The duration
varies from a few days to three months. The rapid fall in the haemoglobin
and in the number of red cells is striking. In half the reported cases the
red count was below 1,500,000 per cmm. With this there is a high color
index. The acute forms are usually of the lymphocytic type, although a few
cases of acute myelogenous leukaemia have been reported. In the former the
predominating lymphocyte is usually the large form, although in a few acute
■cases with haemorrhages the small lymphocytes have been the more numerous.
Diagnosis. — The recognition of leukaemia can be determined only by micro-
scopical examination of the blood. The clinical features may be identical
with those of ordinary splenic angemia, or of Hodgkin's disease. An inter-
esting question arises whether real increase in the leucocytes is the only cri-
terion of the existence of the disease. Thus, for instance, in the case whose
chart is given on page 735, the patient came under observation in September,
1890, with 2,000,000 red blood-corpuscles per cubic millimetre, 30 per cent
-of haemoglobin, and 500,000 white blood-corpuscles per cubic millimetre — a
proportion of 1 to 4. As shown by the chart, throughout September, Octo-
ber, November, and December, this ratio was maintained. Early in January,
under treatment with arsenic, the white corpuscles began to decrease, and
gradually, as shown in the chart, the normal ratio was reached. At this time
could it be said that the case was one of leukaemia without increase in the
number of leucocytes ? The blood examination showed that nucleated red cor-
puscles in large numbers as well as myelocytes, elements which are but rarely
found in normal blood, were still present in numbers sufficient to suggest, if
the patient had come under observation for the first time, that leukaemia might
occur. In another of our cases the blood became normal and the spleen
tumor disappeared twice in one year (McCrae). Altogether I have seen four
cases in which the leucocyte count became normal, in three the splenic enlarge-
ment persisted.
Association with other Diseases. — Tuberculosis, of which Dock has col-
lected 27 cases, occurs occasionally without any special influence on the course.
48
738 DISEASES OF THE BLOOD AND DUCTLESS GLANDS.
Intercurrent infections are not uncommon — influenza, typhoid fever, sepsis —
often with remarkable influence, particularly on the leucocytes. In Dock's case
within a couple of weeks after an attack of influenza they fell from 367,070
to 7,500 per cmm. Various other conditions influence the disease, and the
excess of leucocytes has disappeared after the use of arsenic, quinine, tuber-
culin, nuclein, and the X-rays.
Prognosis. — Eecovery occasionally occurs. A great majority of the cases
prove fatal within two or three years. Unfavorable signs are a tendency to
haemorrhage, persistent diarrhoea, early dropsy, and high fever. Eemarkable
variations are displayed in the course, and a transient improvement may take
place for weeks or even months. The pure lymphatic form seems to be of
particular malignancy, some cases proving fatal in from three to eight weeks.
In one of my cases the leukaemia lasted between eleven and twelve years. The
diagnosis was made by the late W. H. Draper, and when I saw the patient,
ten years after the onset, the cervical, axillary, and inguinal glands were greatly
enlarged; the leucocytes were 243,000 per cubic millimetre, above 90 per cent
of them being lymphocytes. The longest course of my hospital series of the
lymphatic type was three years, and of the spleno-myelogenous about the
same duration.
Treatment. — Fresh air, good diet, and abstention from mental worry and
care, are the important general indications. The indicatio morhi can not be
met. There are certain remedies which have an influence upon the disease.
Of these, arsenic, given in large doses, is the best. I have repeatedly seen
improvement under its use. On the other hand, there are curious remissions
in the disease, as mentioned above, which render therapeutical deductions very
fallacious.
Quinine may be given in eases with a malarial history. Iron may be
of value in some cases, as may also inhalations of oxygen. Treatment with
the X-rays should be tried. Some observers have reported very good results.
Personally, I have not seen any very striking improvement.
Excision of the leuksemic spleen has been performed 43 times, with 5
recoveries (J. C. "Warren).
Chloroma is a rare form of leukaemia in which there is a tumor-like hyper-
plasia of the bone-marrow with growths of a greenish color (" green cancer ")
in the bones, particularly of the head and orbit, and in the organs. There is
anaemia and marked leukaemia. Dock has collected 22 cases reported since
1893. The chief symptoms are progressive weakness, pallor, exophthalmos
with the tumor formations. Sometimes there are skin eruptions, in Bram-
well's case of a greenish color. The cause of the remarkable color is unknown.
ni. HODGKIN'S DISEASE.
Definition. — An affection characterized by progressive enlargement of the
lymphatic glands (beginning usually on one side of the neck) and spleen, with
the formation in the liver, spleen, lungs, and other organs of nodular growths,
associated with a secondary anaemia, without leukaemia.
Hodgkin, in 1832, recorded a series of cases of enlargement of the lym-
phatic glands and spleen. As with Addison's disease, to Wilks we owe a
HODGKIN'S DISEASE. 739
clear conception of the aifection with which he associated the name of the
distinguished morbid anatomist of Guy's Hospital.*
Clinically the cases resemble certain forms of leukaemia, lympho-sarcoma,
and lymphatic tuberculosis; some recent writers even deny the existence of
a separate malady, Hodgkin's disease.
Many names have been given to the condition — ansemia lymphatica
(Wilks), adenie (Trousseau), pseudo-leukfemia (Cohnheim), and generalized
lymphadenoma.
The names malignant lymphoma (Billroth) and lympho-sarcoma have
also been given to a form of progressive enlargement of the lymph-glands,
but they should be restricted to primary sarcoma of these structures, a very
different affection anatomically, though clinically it may resemble Hodgkin's
disease.
Etiolo^. — A majority of the cases occur in young persons. Of 43 cases
collected by Mitchell Clark, 37 were in males. Ten occurred below ten years
of age and 33 below the fortieth year. Heredity, syphilis, and tuberculosis are
doubtful factors. Local irritation about the throat and mouth — regions drain-
ing into the cervical glands — often precedes the onset of the swelling (Trous-
seau). The true nature of the disease is unknown. Certain features suggest
that it may be an acute infection — the rapidly fatal course of some cases, the
frequency with which the disease starts in the cervical glands, and the not
infrequent preliminary involvement of the tonsils, the gradual extension from
one gland-group to another, and the recurring exacerbations of fever. A pos-
sible instance of direct infection is quoted by Murray in Allbutt's system.
The results of bacteriological study are as yet uncertain.
Eelation to Malignant Disease. — Much confusion has come from the
use of the terms lympho-sarcoma and malignant lymphoma to designate cases
of Hodgkin's disease. The two conditions are quite different. We know of
no malignant growth the metastases of which occur in one form of tissue only.
Sarcoma invades the capsule of the gland and the adjacent textures, and
does not limit its extension from one gland-group to another. Histologically
there are radical differences between lympho-sarcoma and Hodgkin's disease.
Eelation to Tuberculosis. — Of late the view has been advanced that
Hodgkin's disease is only a peculiar form of lymphatic tuberculosis, a view
supported by Sternberg, Crowder, Musser, Sailer, and others. There is an
acute tuberculous adenitis and a chronic form (see p. 306), either of which
may closely resemble Hodgkin's disease. The statement of the relationship is
based upon (1) the presence of tubercle bacilli in the glands in a certain
number of cases of Hodgkin's disease, and (2) the successful inoculation of
animals, even when the glands did not show tubercle bacilli microscopically.
Opposed to this are the facts that (1) in a large majority of all cases bacilli
are not present in the glands, and the inoculation experiments are negative
(Westphal) ; (2) the histological changes in the glands in Hodgkin's disease
are specific and distinctive (Eeed) ; (3) the tuberculin test in typical cases
of the disease is negative (Reed) ; and (4) the tuberculosis when present is
in many cases, at least, a terminal infection.
* Students have now easy access to the original account (which appeared in the Trans-
actions of the Eoyal Med. and Chirur. Society, 1832), in the New Sydenham Society Memoirs,
1902,
740 DISEASES OF THE BLOOD AND DUCTLESS GLANDS.
Morbid Anatomy. — The superficial l}Tnph-glands are found most exten-
sively involved, and from the cer^dcal groups they form continuous chains unit-
ing the mediastinal and axillary glands. The masses may pass beneath the pec-
toral muscles and even beneath the scapula?. Of the internal glands, those
of the thorax are most often affected, and the tracheal and bronchial groups
may form large masses. The trachea and the aorta with its branches may be
completely surrounded; the veins may be compressed, rarely the aorta itself.
The masses perforate the sternum and invade the lung deeply. The retro-
peritoneal glands may form a continuous chain from the diaphragm to the
inguinal canals. They may compress the ureters, the lumbar and sacral
nerves, and the iliac veins. They may adhere to the broad ligament and the
uterus and simulate fibroids. At an early stage the glands are soft and elastic;
later they may become firm and hard. Fusion of contiguous glands does not
often occur, and they tend to remain discrete, even after attaining a large size.
The capsule is not infiltrated, nor are adjacent tissues invaded. On section the
gland presents a grayish-white semi-translucent appearance, broken by inter-
secting strands of fibrous tissue; there is no caseation or necrosis unless a
secondary infection has occurred.
The spleen is enlarged in 75 per cent of the cases; in young children the
enlargement may be great, but the organ rarely reaches the size of the spleen
in ordinary leukaemia. In more than half of the cases lymphoid growths are
present.
The marrow of the long bones may be converted into a rich lymphoid
tissue. The lymphatic structures of the tonsillar ring and of the intestines
may show marked hyperplasia. The liver is often enlarged, and may present
scattered nodular tumors, which may also occur in the kidneys.
Histology. — The study of D. M. Eeed,* from the laboratory of my col-
league, Dr. Welch, suggests that there is a specific histological picture in
Hodgkin's disease characterized by (1) proliferation of the endothelial and
reticular cells; (2) the formation of hmphoid cells (uniform in size and
shape) from the mother cells of the h-mph-nodes and from the endothelial
cells of the reticulum; (3) characteristic giant cells, formed from proliferating
endothelial cells, which differ from the giant cells of tuberculosis; (4) great
proliferation of the connective-tissue stroma leading to fibrosis ; and, lastly,
eosinophile cells, which form a marked feature in a large proportion of the
cases. The metastatic nodules present the same structure as the glandular
growths.
When tuberculosis occurs as a secondary infection the two processes may
be readily differentiated in sections of the glands.
Symptoms. — Enlargement of the glands on one side of the neck is usu-
ally the first symptom. It is rare that other superficial groups or the deeper
glands are first attacked. A chronic tonsillitis may precede the onset.
Months, or even several years, may elapse before the glands on the other side
of the neck or in the axilla are involved. Usually there is a progressive
growth, until quite large groups are formed, in which, however, the individual
glands may be felt. There is not often any pain. The inguinal glands may
soon be involved and grow rapidly, but in many cases they do not reach the
* Johns Hopkins Hospital Reports, vol. x, 1902.
HODGKIN'S DISEASjE. 741
size of the cervical groups. During what may be called the first stage of the
disease the patient's general condition is good. It may be many months before
the internal lymph-glands become involved, and they may never enlarge suffi-
ciently to cause symptoms. The spleen enlarges in a majority of cases. In
rare instances the lymphoid tumors may be felt on the surface of the enlarged
liver and spleen.
As the disease advances the symptoms fall into two groups — those due
to pressure of the enlarged glands, and the progressive cachexia. The axillary
groups may cause swelling and pain in the hands and arms. The inguinal
glands may press on the nerves and cause great pain, with swelling of the feet.
Involvement of the mediastinal glands is indicated by paroxysmal cough,
attacks of pain, dyspnoea, and sometimes most intense cyanosis of the upper
part of the body. Pleural effusion, disturbed heart action, and pupillary
changes are rarer events. The cases with paraplegia from invasion of the
spine and the cord, are, as a rule, lympho-sarcoma.
The general symptoms of the disease are:
Anemia of a secondary type, not marked at first, and even in the later
stages the red corpuscles rarely fall below 2,000,000 per cubic millimetre. The
leucocytes may be normal in number or there may be an early leucocytosis, or
at any time during the course there may be a transient increase. The small
mononuclear forms may be relatively increased. In very rare instances a ter-
minal leukgemia occurs, but, as C. F. Martin suggests, these cases may be true
leukaemia from the start.
Fever. — A majority of the cases present (1) a slight irregular fever;
(2) later in the disease there may be a daily rise of three or four degrees,
sometimes with a chill and sweat; (3) in a few rare instances Pel has de-
scribed remarkable periods of fever of ten to fourteen days' duration, alter-
nating with intervals of complete apyrexia. They occurred in two of my cases.
Ebstein described it as a form of chronic recurring fever. It is probably due
to an intercurrent infection,
Cachexia.-^A remarkable grade of emaciation ultimately follows, associ-
ated with great asthenia, and sometimes anasarca from the anaemia.
Bronzing of the skin may occur, apart from the use of arsenic. An obsti-
nate pruritus and recurring boils may add to the patient's distress.
Diagnosis.— (a) Tuberculosis. — It is not sufficiently recognized that there
are both acute and chronic forms of general tuberculous adenitis (see p. 306),
but such cases, do not often present difficulty in diagnosis. In the case of
enlargement of the glands on one side of the neck beginning in a young per-
son, it is often not at all easy to determine whether the disease is tuberculosis
or beginning Hodgkin's disease. Two points should be decided. First, under
cocaine one of the small glands of the affected side should be excised and the
structure carefully studied in the light of Dr. Eeed's recent observations. The
histological changes differ markedly in Hodgkin's disease from those in tuber-
culosis. Secondly, tuberculin should be used if the patient is afebrile. In
early tuberculosis of the glands of the neck the reaction is prompt and decisive.
The large experience on this point in the wards of my colleague, Halsted, is
conclusive as to the efficiency (and the harmlessness) of the method. In the
later stages, when many groups of glands are involved and the cachexia is well
advanced, the tuberculin reaction may be present in Hodgkin's disease, but
742 DISEASES OF THE BLOOD AND DUCTLESS GLANDS.
even then the histological changes are distinctive. Other points to be noted are
the tendency in the tuberculous adenitis to coalescence of the glands, adhesion
to the skin, Tvith suppuration, etc., and the liability to tuberculosis of the lung
or pleura.
(6) Leukemia. — As a rule, the blood examination gives the diagnosis at
a glance, as Hodgkin's disease presents only a slight leucocytosis. A dif-
ficult)^ arises only in those rare instances of leuksemia, usually the acute l}Tn-
phatic form, in which the leucocytes gradually decrease or in wliich the number
for a time may become normal. Histologically there are striking differences
between the structure of the glands in the two conditions.
(c) Ltmpiio-saecoma. — Clinically the cases may resemble Hodgkin's dis-
ease very closely, and in the literature the two diseases have been confounded.
The glands, as a rule, form larger masses, the capsules are involved, and
adjacent structures are attacked. Pressure signs in the chest and abdomen are
much more common in hmipho-sarcoma. But the easiest and most satisfactory
mode of diagnosis is examination of sections of a gland, as the structure is very
different from that seen in Hodgkin's disease. The blood condition, the type
of fever, etc., need a more careful study in this group of cases.
Course. — There are acute cases in which the enlargements spread rapidly
and death follows in three or four months. As a rule, the disease lasts for
two or three years. Eemarkable periods of quiescence may occur, in which the
glands diminish in size, the fever disappears, and the general condition im-
proves. Even a large group of glands may almost completely disappear, or
a tumor mass on one side of the neck may subside while the inguinal glands
are enlarging. Usually a cachexia with anaemia and swelling of the feet pre-
cedes death. A fatal event may occur early from great enlargement of the
mediastinal glands.
Treatment. — When the glands are small and limited to one side of the
neck, operation should be advised; even when both sides of the neck are in-
volved, if there are no signs of mediastinal growth, operation is justifiable.
The course of the disease may be delayed, even if cure does not follow.
There is a possibility that the X-rays may do good in selected cases. Cer-
tainly the glands have been reduced in size, but I know of no case in which
complete cure has been reported. Local treatment of the glands seems to do
but little good.
Arsenic is the only drug which has a positive value in the disease. In
some cases the effects on the glands are striking. It may be given in the form
of Fowler's solution in increasing doses. Eecoveries have been reported (?).
Ill effects from the larger doses are rare. Peripheral neuritis followed the
use of I iv, 5j, TT], xviij during a period of less than three months. Phosphorus
is recommended by Gowers and Broadbent, and may be tried if arsenic is not
well borne. Quinine, iron, and cod-liver oil are useful as tonics. For the
pressure pains morphia should be given.
IV. PURPURA.
Strictly speaking, purpura is a symptom, not a disease; but under this
term are conveniently arranged a number of affections characterized by extrav-
asations of the blood into the skin. In the present state of our knowledge a
PURPURA. 743
satisfactory classification can not be made. W. Koch groups all forms, includ-
ing haemophilia, under the designation hcemorrhagic diathesis, believing that
intermediate forms link the mild purpura simplex and the most intense pur-
pura hsemorrhagica. For a full discussion of the subject and an analysis of
my cases, see Pratt's article in my " System of Medicine," Vol. IV.
The purpuric spots vary from 1 to 3 or 4 mm. in diameter. When small
and pin-point-like they are called petechise; when large, they are known as
€cchymoses. At first bright red in color, they become darker, and gradually
fade to brownish stains. They do not disappear on pressure.
In all cases of purpura the coagulation time of the blood should be esti-
mated (Wright) ; the coagulometer is a useful clinical instrument for the pur-
pose. Normal blood clots in the tubes in from three to five minutes. In some
forms of purpura the coagulation time is retarded to ten or fifteen minutes,
and in haemophilia it has been delayed to fifty minutes.
The following is a provisional grouping of the cases :
Symptomatic Purpura. — (a) Infectious. — In pyaemia, septicemia, and
malignant endocarditis (particularly in the last affection), ecchymoses may
he very abundant. In typhus fever the rash is always purpuric. Measles, scar-
let fever, and more particularly small-pox and cerebro-spinal fever, have each a
Tariety characterized by an extensive purpuric rash.
(&) Toxic. — The virus of snakes produces with great rapidity extrava-
sation of blood' — a condition which has been very carefully studied by Weir
Mitchell. Certain medicines, particularly copaiba, quinine, belladonna, mer-
cury, ergot, and the iodides occasionally, are followed by a petechial rash.
Purpura may follow the use of comparatively small doses of iodide of potas-
sium. It is not a very common occurrence, considering the great frequency
with which the drug is employed. A fatal event may be caused by a small
.amount, as in a case reported by Stephen Mackenzie of a child which died after
.a dose of 2^ grains. Ah erythema may precede the haemorrhage. It is not
.always a simple purpura, but may be an acute febrile eruption of great inten-
sity. In September, 1894, a man aged forty-eight was admitted under my
■eare with arterio-sclerosis and dropsy. The latter yielded rapidly to digitalis
and diuretin. When convalescent he was ordered iodide of potassium in 10-
.grain doses three times a day, and took in fourteen days 420 grains. He had
high fever, coryza, swelling of the throat, and the most extensive purpura
over the whole body. I saw in an adult an extensive purpura of the skin of the
legs follow the taking of 60 grains of the drug in four doses. Under this
■division, too, comes the purpura so often associated with jaundice.
(c) Cachectic. — Under this heading are best described the instances of
purpura which occur in the constitutional disturbance of cancer, tuberculosis,
Hodgkin's disease, Bright's disease, scurvy, and in the debility of old age. In
these cases the spots are usually confined to the extremities. They may be very
abundant on the lower limbs and about the wrists and hands. This constitutes,
probably, the commonest variety of the disease, and many examples of it can
'be seen in the wards of any large hospital.
(d) ISTeurotic. — One variety is met with in cases of organic disease. It
is the so-called myelopathic purpura, which is seen occasionally in locomotor
ataxia, particularly following attacks of the lightning pains and, as a rule,
involving the area of the skin in which the pains have been most intense.
744 DISEASES OF THE BLOOD AND DUCTLESS GLANDS.
Cases have been met with also in acute myelitis and in transverse myelitis,,
and occasionally in severe neuralgia. Another form is the remarkable hysteri-
cal condition in which stigmata, or bleeding points, appear upon the skia.
(e) Mechaxical. — This variety is most frequently seen in venous stasis
of any form, as in the paroxysms of whooping-cough and in epilepsy and
about tight bandages.
Arthritic. — This form is characterized by involvement of the joints. It
is usually known, therefore, as rheumatic, though in reality the evidence upon
which this view is based is not conclusive. Of 200 cases of purpura analyzed
by Stephen Mackenzie, 61 had a history of rheumatism. For the present it
seems more satisfactory to use the designation arthritic. Three groups of
cases may be recognized :
{a) iPuEPUEA Simplex. — A mild form, often known as purpura simplex,
seen most commonly in children, in whom, with or without articular pain, a
crop of purpuric spots appears upon the legs, less commonly upon the trunk
and arms. As pointed out by Graves, this form is not infrequently associated
with diarrhoea. The disease is seldom severe. There may be loss of appetite,
and slight angemia. Fever is not, as a rule, present, and the patients get well
in a week or ten days. Usually regarded as rheumatic, and certainly asso-
ciated, in some instances, with undoubted rheumatic manifestations, yet in a
majority of the patients the arthritis is slighter than in the ordinary rheuma-
tism of children, and no other manifestations are present.
(h) PuEPUEA (Peliosis) Eheumatica {ScJwnlein's Disease) . — This re-
markable affection is characterized by multiple arthritis, and an eruption
which varies greatly in character, sometimes purpuric, more commonly asso-
ciated with urticaria or with erythema exudativum. The disease is most
common in males between the ages of twenty and thirty. It not infrequently
sets in with sore throat, a fever from 101° to 103°, and articular pains. The
rash, which makes its appearance first on the legs or about the affected joints,
may be a simple purpura or may show ordinary urticarial wheals. In other
instances there are nodular infiltrations, not to be distinguished from erythema
nodosum. The combination of wheals and purpura, the purpura urticans, is
very distinctive. Much more rarely vesication is met with, the so-called
pemphigoid purpura. The amount of cedema is variable; occasionally it is
excessive. In one case, which I saw in Montreal with Molson, the chin and
lower lip were enormously swollen, tense, glazed, and deeply ecch^-motic. The
eyelids were swollen and purpuric, while scattered over the cheeks and about
the joints were numerous spots of purpura urticans. These are the cases which
have been described as felrile purpuric (xdema. The temperature range, in
mild cases, is not high, but may reach 102° or 103°.
The urine is sometimes reduced in amount and may be albuminous. The
joint affections are usually slight, though associated with much pain, par-
ticularly as the rash comes out. Eelapses may occur and the disease may
return at the same time for several years in succession.
The diagnosis of Schonlein's disease offers no difficulty. The association
of multiple arthritis wdth purpura and urticaria is very characteristic. In a
case which I saw with Musser there Aras endo-pericarditis, and the question
at first arose whether the patient had malignant endocarditis with extensive
cutaneous infarcts.
PURPURA. 745
Schonlein's peliosis is thought by most writers to be of rheumatic origin,
and certainly many of the cases have the characters of ordinary rheumatic
fever, plus purpura. By many, however, it is regarded as a special affection^
of which the arthritis is a manifestation analogous to that which occurs in
haemophilia and in scurvy. The frequency with which sore throat precedes
the attack, and the occasional occurrence of endocarditis or pericarditis, are
certainly very suggestive of true rheumatism.
The cases usually do well, and a fatal event is extremely rare. The throat
symptoms may persist and give trouble. In two instances I have seen necrosis
and sloughing of a portion of the uvula.
(c) Purpura, Erythema, and Urticaria with Visceral Lesions. —
This variety, seen chiefly in children, is characterized by (1) relapses or recur-
rences, often extending over several years; (2) cutaneous lesions, which may
be simple purpura, purpura urticans, urticaria, angio-neurotic oedema, and
erythema in all its multiform varieties; in successive attacks the skin lesions
may vary greatly; (3) gastro-intestinal crises — pain, vomiting, and diarrhoea;
(4) joint pains or swelling, often trifling; (5) haemorrhages from the mucous
membranes; (6) enlargement of the spleen; (7) nephritis, which is the most
serious feature and the most frequent cause of death. The cases with colic
and purpura are often spoken of as Henoch's purpura, but the skin lesion is
very variable. The whole group of symptoms is really a manifestation of an as
yet unknown mischief, which at one time attacking the skin causes any of the
manifestations of the erythema group, from simple purpura to angio-neurotic
oedema, attacking the intestines or stomach causes vomiting, colic, or bleeding,
or attacking the kidneys an acute and sometimes fatal nephritis. (For a study
of twenty-eight cases see American Journal of Medical Sciences, January,
1904.)
Purpura Hsemorrhag^ica. — Under this heading may be considered the cases
of very severe purpura with haemorrhages from the mucous membranes. The
affection, known as the morbus maculosus of Werlhof, is most commonly met
with in young and delicate individuals, particularly in girls; but cases are
described in which the disease has attacked adults in full vigor. After a
few days of weakness and debility, purpuric spots appear on the skin and
rapidly increase in numbers and size. Bleeding from the mucous surfaces sets
in, and the epistaxis, haematuria, and hsemoptysis may cause profound anaemia.
Chart XX illustrates the rapidity with which anaemia is produced and the
gradual recovery. Death may take place from loss of blood, or from haemor-
rhage into the brain. Slight fever usually accompanies the disease. In favor-
able cases the affection terminates in from ten days to two weeks. There are
instances of purpura haemorrhagica of great malignancy, which may prove
fatal within twenty-four hours — purpura fulminans. This form is most com-
monly met with in children, and is characterized chiefly by cutaneous haemor-
rhages, and death may occur before any bleeding takes place from the mucous
membranes.
In the diagnosis of purpura haemorrhagica it is important to exclude
scurvy, which may be done by the consideration of the previous health, the
cirqumstances under which the disease occurs, and by the absence of swelling
of the gums. The malignant forms of the fevers, particularly small-pox and
measles, are distinguished by the prodromes and the higher temperature.
746
DISEASES OF THE BLOOD AND DUCTLESS GLANDS.
Treatment. — In symptomatic purpura attention should be paid to the con-
ditions under which it occurs, and measures should be emploj^ed to increase
the strength and to restore a normal blood condition. Tonics, good food, and
fresh air meet these indications. In the simple purpura of children, or that
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BLACK,_RED CCSPUSCLE3. RED, HAEMAGLOBIN, BLUE, COLORLESS CORPUSCLES.
Chart XX. — Illustrates the Rapidity with which Anemia is Produced in Purpura
HEMORRHAGICA AND THE GRADUAL RECOVERY.
associated with slight articular trouble, arsenic in full doses should be given.
No good is obtained from the small doses, but the Fowler's solution should be
pushed freely until physiological effects are obtained. In peliosis rheumatica
the sodium salicylate may be given, but with discretion. I confess not to
have seen any special control of the hemorrhages by this remedy.
Aromatic sulphuric acid, ergot, turpentine, acetate of lead, or tannic and
gallic acids, may be given, and in some instances they seem to check the bleed-
ing. Oil of turpentine is perhaps the best remedy, in 10 or 15 minims doses
three or four times a day. Wright, of Xetley, advises the use of calcium
chloride in 20-grain doses four times a day (for three or four days) to
increase the coagulability of the blood. In bleeding from the mouth, gums,
and nose, the inhalation of carbon dioxide, irrigations with 2-per-cent gelatin
solution, and adrenalin should be tried. The last remedy has often acted
promptly.
HMMOPHILIA. J 41
H-'EMORRHAGIC DISEASES OF THE NeW-BORN.
1. Syphilis Hsemorrhagica Neonatorum. — The child may be born healthy,
or there may be signs of hemorrhage at birth. Then in a few days there
are extensive cutaneous extravasations and bleeding from the mucous sur-
faces and from the navel. The child may become deeply jaundiced. The
post mortem shows numerous extravasations in the internal organs and exten-
sive syphilitic changes in the liver and other organs.
2. Epidemic Haemoglobinuria {WinckeVs Disease). — Hemoglobinuria in
the new-born, which occasionally occurs in epidemic form in lying-in insti-
tutions, is a very fatal affection, which sets in usually about the fourth day
after birth. The child becomes jaundiced, and there are marked gastro-intes-
tinal symptoms, with fever, jaundice, rapid respiration, and sometimes cyano-
sis. The urine contains albumin and blood-coloring matter — methaemoglobin.
The disease has to be distinguished from the simple icterus neonatorum, with
which there may sometimes be blood or blood-coloring matter in the urine.
The post mortem shows an absence of any septic condition of the umbilical
vessels, but the spleen is swollen, and there are punctiform haemorrhages in
different parts. Some cases have shown in a marked degree acute fatty degen-
eration of the internal organs — the so-called Buhl's disease.
3. Morbus Maculosus Neonatorum. — Apart from the common visceral
haemorrhages, the result of injuries at birth, bleeding from one or more of
the surfaces is a not uncommon event in the new-born, particularly in hos-
pital practice. Forty- five cases occurred in 6,700 deliveries (C. W. Townsend).
The bleeding may be from the navel alone, but more commonly it is general.
Of Townsend's 50 cases, in 20 the blood came from the bowels (melcena neo-
natorum), in 14 from the stomach, in 14 from the mouth, in 13 from the nose,
in 18 from the navel, in 3 from the navel alone. The bleeding begins within
the first week, but in rare instances is delayed to the second or third. Thirty-
one of the cases died and 19 recovered. The disease is usually of brief dura-
tion, death occurring in from one to seven days. The temperature is often
elevated. The nature of the disease is unknown. As a rule, nothing abnor-
mal is found post mortem. The general and not local nature of the affection,
its self-limited character, the presence of fever, and the greater prevalence
of the disease in hospitals, suggest an infectious origin (Townsend). The
bleeding may be associated with intense hsematogenous jaundice. Not every
case of bleeding from the stomach or bowels belongs in this category. Ulcers
of the oesophagus, stomach, and duodenum have been found in the new-born
dead of melcena neonatorum. The child may draw the blood from the breast
and subsequently vomit it. In the treatment the external warmth must be
maintained, and in feeble infants the couveuse may be used. Camphor is
recommended, ergotin hypodermically, and the suprarenal extract.
V. HEMOPHILIA.
Definition. — A constitutional fault, hereditary or acquired, characterized
by a tendency to uncontrollable bleeding, either spontaneous or from slight
wounds, sometimes associated with a form of arthritis. The coagulation time
of the blood is usuall}'' much retarded.
748 DISEASES OF THE BLOOD AND DUCTLESS GLANDS.
The fact that fatal haemorrhage might occur from slight^ trifling wounds
had been known for centuries. Fordyce, in 1784, recognized the hereditary-
nature, and early in the last century described the American bleeder families.
Buel, Otto, Hay, Coates, and others in America published similar reports. The
disease is considered at length in the monographs of Legg and Grandidier, and
recently by Stempel.
Etiology. — In a majority of cases the disposition is hereditary. In the
Appleton- Swain famih^, of Reading, Mass., there have been cases for nearly
two centuries; and F. F. Brown, of that town, teUs me that instances have
already occurred in the seventh generation. Atavism through the female alone
is almost the rule, and the daughters of a bleeder, though healthy and free
irom any tendency, are almost certain to transmit the disposition to the male
offspring. The affection is much more common in males than in females —
11 :1, Legg; 4 :1, Stempel. The tendency usually appears within the first two
years of life. It is rare for manifestations to be delayed until the tenth or
twelfth year. Families in all conditions of life are affected. The bleeder
families are usually large. The members are healthy-looking, and have fine,
soft skins. The Anglo-German races are chiefly attacked; of 209 cases col-
lected within the ten years 1890-1900 by Stempel, 96 were German, 95 Eng-
lish or American, only 16 French, Hungarian, or Eussian. Steiner has re-
ported from my clinic instances occurring in a negro family.
Morbid Anatomy. — No special peculiarities have been described. In some
instances changes have been found in the smaller vessels ; but in others careful
studies have been negative. An unusual thinness of the vessels has been noted.
Haemorrhages have been found in and about the capsules of the joints, and in
a few iostances inflammation of the synovial surfaces. The nature of the dis-
ease is imknown. An increase in the number of the red blood-corpuscles — ery-
throcythsemia — with a peculiar frailty of the blood-vessels, has been supposed.
A deficiency of the leucocytes and a diminution of the blood-plates have been
noted, though in a case from my clinic, studied by Steiner, these structures
were normal. Wright has found the coagulation time much retarded, as long
as twenty-three and forty-five minutes.
Symptoms. — Usually hsemophilia is not noted in the child until a trifling
cut is followed by serious or uncontrollable hgemorrhage, or spontaneous bleed-
ing occurs and presents insuperable difficulties in its arrest. The symptoms
may be grouped under three divisions : external bleedings, spontaneous and
traxmiatic; interstitial bleedings, petechige and ecch}-moses; and the joint affec-
tions. The external bleedings may be spontaneous, but more commonly they
follow cuts and wounds. In 334 cases (Grandidier) the chief bleedings were
epistaxis, 169; from the mouth, 43; stomach, 15; bowels, 36; urethra, 16;
lungs, 17; and in a few instances bleeding from the skin of the head, the
tongue, finger-tips, tear-papilla, eyelids, external ear, vulva, navel, and
scrotum.
Traumatic bleeding may result from blows, cuts, scratches, etc., and the
blood may be diffused into the tissues or discharged externally. Trivial opera-
tions have proved fatal, such as the extraction of teeth, circumcision, or vene-
section. It is possible that there may be local defects which make bleeding
from certain parts of the body more dangerous. D. Hayes Agnew mentioned
to me the case of a bleeder who had alwavs bled from cuts and bruises above
HEMOPHILIA. 749
the neck, never from those below. The bleeding is a capillary oozing. It may
last for hours, or even many days. Epistaxis may prove fatal in twenty-four
hours. In the slow bleeding from the mucous surfaces large blood tumors may
form and project from the nose or mouth, forming remarkable-looking struc-
tures, and showing that the blood has the power of coagulation. The inter-
stitial haemorrhages may be spontaneous, or may result from injury. Petechias
or large extravasations — haematomata — may occur, particularly after blows.
Joint Affections. — The knees and elbows are chiefly involved, but the small
joints may be attacked. The onset is usually acute, with slight fever and
swelling and pain, and sometimes redness. In other instances there is haemor-
rhagic effusion without fever. Konig recognizes three stages: first, haemar^
throsis; secondly, an inflammatory process, with fever and spindle-formed
swelling, which is apt to be mistaken for tuberculosis; and, lastly, there may
be extensive organic changes, which may even resemble those of arthritis
deformans. There are cases with spontaneous haemorrhages into muscles and
joints without (for years at least) external bleedings.
Abdominal Symptoms. — Intestinal crises, similar to those which occur in
purpura, may be present and are of great importance, as the diagnosis of
appendicitis may be made. I have seen two cases.
Diagnosis. — In the diagnosis of the condition the family tendency is impor-
tant. A single uncontrollable haemorrhage in child or adult is not to be ranked
as haemophilia; but it is only when a person shows a marked tendency to mul-
tiple haemorrhages, spontaneous or traumatic, which tendency is not transitory
but persists, and particularly if there have been joint affections, that we may
consider the condition haemophilia. Such conditions as epistaxis, recurring for
years — if no other haemorrhage occurs — or recurring haematuria from one kid-
ney, which has been spoken of as unilateral renal haemophilia, have no associa-
tion with the true disease. There is a remarkable form of hereditary epistaxis
with multiple cutaneous naevi — telangiectases. The bleeding comes from the
dilated spider naevi in the nose, or on the lips, tongue, or cheeks (/. H. H.
Bulletin, IdOl) . Peliosis rheumatica is an affection which touches haemophilia
very closely, particularly in the relation of the joint swellings. It may also
show itself in several members of a family. The diagnosis from the various
forms of purpura is usually easy.
Prognosis. — The patients rarely die in the first bleeding. The younger
the individual the worse is the outlook, though children rarely die in the first
year. Grandidier states that of 152 boy subjects, 81 died before the termi-
nation of the seventh year. The longer the bleeder survives the greater the
chance of his outliving the tendency; but it may persist to old age, as shown
in the case of Oliver Appleton, the first reported American bleeder, who died
at an advanced age of haemorrhage from a bed-sore and from the urethra.
The prognosis is graver in a boy than in a girl. In the latter menstruation
is sometimes early and excessive, but fortunately, in the female members of
haemophilic families, neither this function nor the act of parturition brings
with it special dangers.
Treatment. — Members of a bleeder's family, particularly the boys, should
be guarded from injury, and operations of all sorts avoided. The daughters
should not marry, as it is through them that the tendency ■ is propagated.
Wh^n an injury or wound has occurred, absolute rest and compression
750 DISEASES OF THE BLOOD AND DUCTLESS GLANDS.
should first be tried, and if these fail the styptics may be used. In epistaxis
ice, tannic and gallic acid may be tried before resorting to plugging. Internally
ergot seems to have done good in several cases. Legg advises the perchloride
of iron in half-drachm doses every two hours with a purge or sulphate of soda.
For the epistaxis the inhalation of carbon dioxide through the nostrils is
recommended by A. E. Wright. He also advises a solution of fibrin ferment
and chloride of calcium as a st}^tic. Dried suprarenal gland, 1 part to 10^
of water, freshly prepared, may be applied to the part, or the active principle,
epinephrin or adrenalin, may be tried. Gelatin in 5-per-cent solution is warmly
recommended. Venesection has been tried in several cases. Transfusion has
been employed, but without success. During convalescence, iron and arsenic
should be freely used.
VI. SCURVY (Scorbutus).
Definition. — A constitutional disease characterized by great debility, with
angemia, a spongy condition of the gums, and a tendency to haemorrhages.
Etiology. — The disease has been known from the earliest times, and has
prevailed particularly in armies in the field and among sailors on long voy-
ages. It has been well called " the calamity of sailors."
From the early part of the last century, owing largely to the efforts of
Lind and to a knowledge of the conditions upon which the disease depends,,
scurvy has gradually disappeared from the naval service. In the mercantile
marine, cases still occasionally occur, owing to the lack of proper and suitable
food.
In parts of Eussia scurvy is endemic, at certain seasons reaching epidemic
proportions; and the leading authorities upon the disorder, now in that coun-
try, are almost unanimous, according to Hoffmann, in regarding it as infec-
tious.
In the United States scurvy has become a very rare disease. To the hos-
pitals in the seaport towns sailors are now and then admitted with it. In.
large almshouses outbreaks occasionally occur. A very great increase of for-
eign population of a low grade has in certain districts made the disease not
at all uncommon. In the mining districts of Pennsylvania the Hungarian,
Bohemian, and Italian settlers are not infrequently attacked. McGrew has
recently reported 43 cases in Chicago, limited entirely to Poles. He ascer-
tained that in a large proportion of the cases the diet was composed of bread
strong coffee, and meat. Occasionally one meets with scurvy among quite
well-to-do people. One of the most characteristic cases I have ever seen was
in a woman with chronic dyspepsia, who had lived for many months chiefly
on tea and bread. Some years ago ■ scurvy was not infrequent in the large
lumbering camps in the Ottawa Valley, In Great Britain and Ireland it has
become very rare; only 302 cases were admitted to the Seaman's Hospital in
the twenty-two years ending 1896 (Johnson Smith). Judging from the Ee-
port of the American Pediatric Society, we must infer that infantile scurvy is-
on the increase in the United States.
The precise cause is unknown; there are three theories of the disease:
(a) That it is the result of an absence of those ingredients in the food
which are supplied by fresh vegetables. What these constituents are has not
SCURVY. 751
yet been definite!}' determined. Garrod holds that the defect is the absence
of the potassic salts. Others believe that the essential factor is the absence
of the organic salts present in fruits and vegetables. Ealfe believed that the
absence from the food of the malates, citrates, and lactates reduces the alka-
linity of the blood; and Wright has brought forward evidence which suggests
that it may be an acid intoxication.
(&) That it is due to toxic materials in the foods — some unknown organic
poison the product of decomposition. That it is not due to an absence of
fresh vegetables or the salts of fruits and vegetables seems to have been settled
by Nansen and his comrades, who, living for months under the most unfavor-
able hygienic surroundings, but eating fresh bear's meat and bear's blood,
escaped scurvy. Hoist and Frolich in their recent work oppose this toxic view,
and maintain that the disease is due to the lack in the food of nutrient con-
stituents which so far have not been identified.
(c) In opposition to these chemical views it is urged that the disease
depends upon a specific (as yet unknown) micro-organism.
Other factors play an important part in the disease, particularly physical
and moral influences — overcrowding, dwelling in cold, damp quarters, and
prolonged fatigue under depressing influences, as during the retreat of an
army. Among prisoners, mental depression plays an important role. It is
stated that epidemics of the disease have broken out in the French convict-
ships en route to New Caledonia even when the diet was amply sufficient.
Nostalgia is sometimes an important element. It is an interesting fact
that prolonged starvation in itself does not necessarily cause scurvy. Not
one of the professional fasters of late years has displayed any scorbutic symp-
tom. The disease attacks all ages, but the old are more susceptible to it.
Sex has no special influence, but during the siege of Paris it was noted that the
males attacked were greatly in excess of the females.
Morbid Anatomy. — The anatomical changes are marked, though by no
means specific, and are chiefly those associated with haemorrhage. The blood
is dark and fluid. The microscopical alterations are those of a severe ansemia,
without leucocytosis. The bacteriological examination has not yielded any-
thing very positive. Practically there are no changes in the blood, either ana-
tomical or chemical, which can be regarded as peculiar to the disease. The
skin shows the ecchymoses evident during life. There are haemorrhages into
the muscles, and occasionally about or even into the joints. Haemorrhages
occur in the internal organs, particularly on the serous membranes and in the
kidneys and bladder. The gums are swollen and sometimes ulcerated, so that
in advanced cases the teeth are loose and have even fallen out. Ulcers are
occasionally met with in the ileum and colon. Haemorrhages into the mucous
membranes are extremely common. The spleen is enlarged and soft. Paren-
chymatous changes are constant in the liver, kidneys, and heart.
Symptoms. — The disease is insidious in its onset. Early symptoms are
loss in weight, progressive weakness, and pallor. Very soon the gums are
noticed to be swollen and spongy, to bleed easily, and in extreme cases to pre-
sent a fungous appearance. These changes, regarded as characteristic, are
sometimes absent. The teeth may become loose and even fall out. Actual
necrosis of the jaw is not common. The breath is excessively foul. The
tongue is swollen, but may be red and not much furred. The salivary glands
752 DISEASES OF THE BLOOD AND DUCTLESS GLANDS.
are occasionally enlarged. Haemorrhages beneath the mucous membranes of
the mouth are common. The skin becomes dry and rough, and ecchymoses
soon appear, first on the legs and then on the arms and trunk, and particularly
into and about the hair-follicles. They are petechial, but may become larger,
and when subcutaneous may cause distinct swellings. In severe cases, par-
ticularly in the legs, there may be effusion between the periosteum and the
bone, forming irregular nodes, which may break down and form foul-looking
sores. The slightest bruise or injur}^ causes hgemorrhages into the injured
part. (Edema about the ankles is common. The " scurvy sclerosis," seen
oftenest in the legs, is a remarkable infiltration of the subcutaneous tissues and
muscles, forming a brawny induration, the skin over which may be blood-
stained. Haemorrhages from the mucous membranes are less constant symp-
toms ; epistaxis_is, however, frequent. Hgemoptysis and hsematemesis are
uncommon. Hsematuria and bleeding from the bowels may be present in
very severe cases.
Palpitation of the heart and feebleness and irregularity of the impulse
are prominent symptoms. A hsemic murmur can usually be heard at the
base. Hsemorrhagic infarction of the lungs and spleen has been described.
Respiratory symptoms are not common. The appetite is impaired, and owing
to the soreness of the gums the patient is unable to chew the food. Constipa-
tion is more frequent than diarrhoea. Pain, tenderness, or swelling in the
joints were present in 13 of McG-rew's 42 cases. The urine is often albu-
minous. The changes in its composition are not constant ; the specific gravity
is high; the color is deeper. The statements with reference to the inorganic
constituents are contradictory. Some authorities have found the phosphates
and potassium salts to be deficient : others hold that they are increased.
There are mental depression, indifference, in some cases headache, and
in the later stages delirium. Cases of convulsions, of hemiplegia, and of
meningeal haemorrhage have been described. Eemarkable ocular symptoms are
occasionally met with, such as night-blindness or day-blindness.
In advanced cases necrosis of the bones may occur, and in young persons
even separation of the epiphyses. There are instances in which the cartilages
have separated from the sternum. The callus of a recently repaired fracture
has been known to undergo destruction. Fever is not present, except in the
later stages, or when secondary inflammations in the internal organs appear.
The temperature may, indeed, be sometimes below normal. Acute arthritis
is an occasional complication.
Diagnosis. — No difficulty is met in the recognition of scurv}'" when a num-
ber of persons are affected together. In isolated cases, however, the disease
is distinguished with difficulty from certain forms of purpura. The associa^
tion with manifest insufficiency in diet, and the rapid amelioration with suit-
able food, are points by which the diagnosis can be readily settled.
Prognosis. — The outlook is good, unless the disease is far advanced and the
conditions persist which lead to its occurrence. The mortalit}^ now is rarely
great. Death results from gradual heart-failure, occasionally from sudden
syncope. Meningeal haemorrhage, extravasation into the serous cavities, entero-
colitis, and other intercurrent affections may prove fatal.
Prophylaxis. — The regulations of the Board of Trade require that a suffi-
cient supply of antiscorbutic articles of diet be taken on each ship ; so that
SCURVY. 753
now, except as the result of accident, the occurrence of scurvy is rare in
sailors.
Treatment. — The juice of two or three lemons daily and a diet of plenty
of meat and fresh vegetables suffice to cure all cases of scurvy, unless far
advanced. When the stomach is much disordered, small quantities of scraped
meat and milk should be given at short intervals, and the lemon-juice in grad-
ually increasing quantities. A bitter tonic, or a steel and bark mixture, may
be given. As the patient gains in strength, the diet may be more liberal, and
he may eat freely of potatoes, cabbage, water-cresses, and lettuce. The stoma-
titis is the symptom which causes the greatest distress. The permanganate
of potash or dilute carbolic acid forms the best mouth-wash. Pencilling the
swollen gums with a tolerably strong solution of nitrate of silver is very useful.
The solution is better than the solid stick, as it reaches to the crevices between
the granulations. The constipation which is so common is best treated with
large enemata. For other conditions, such as haemorrhages and ulcerations,
suitable measures must be employed.
Infantile Scurvy {Barlow's Disease).
As in adults, scurvy may occur in children in consequence of imperfect
food supply.
W. B. Cheadle and Gee, in London, have described in very young children
a cachexia associated with haemorrhage. Cheadle regarded the cases as scurvy
ingrafted on a rickety stock. Gee called his cases periosteal cachexia. Cases
had previously been regarded as acute rickets.
A few years later Barlow made an exhaustive study of the condition with
careful anatomical observations. The affection is now recognized as infantile
scurvy, and is called Barlow's disease. The American Paediatric Society has
collected (1898) in the United States 379 cases. Of these, the hygienic sur-
roundings were good in 303. A majority of the patients were under twelve
months. The proprietary foods, particularly malted milk and condensed milk,
seem to be the most important factors in producing the disease. There are
instances in which it has developed in breast-fed infants, and in others fed
on^ the carefully prepared milk of the Walker-Gordon laboratories.
The following is a general clinical summary, taken from Barlow's de-
scription :
" So long as it is left alone the child is tolerably quiet; the lower limbs
are kept drawn up and still ; but when placed in its bath or otherwise moved
there is continuous crying, and it soon becomes clear that the pain is con-
nected with the lower limbs. At this period the upper limbs may be touched
with impunity, but any attempt to move the legs or thighs gives rise to
screams. Next, some obscure swelling may be detected, first on one lower
limb, then on the other, though it is not absolutely symmetrical. . . . The
swelling is ill-defined, but is suggestive of thickening round the shafts of the
bones, beginning above the epiphyseal junctions. Gradually the bulk of the
limbs affected becomes visibly increased. . . . The position of the limbs be-
comes somewhat different from what it was at the outset. Instead of being
flexed they lie everted and immobile, in a state of pseudo-paralysis. . . .
About this time, if not before, great weakness of the back becomes manifest.
49
754 DISEASES OF THE BLOOD AND DUCTLESS GLANDS.
A little swelling of one or both scapulas may aj^pear, and the upper limbs
may show changes. These are rarely so considerable as the alterations in
the lower limbs. There may be swelling above the wrists, extending for a short
distance up the forearm, and some swelling in the neighborhood of the epi-
physes of the humerus. There is symmetry of lesions, but it is not absolute;
and the limb affection is generally consecutive, though the involvement of one
limb follows very close upon another. The joints are free. In severe cases
another symptom may now be found — ^namely, crepitus in the regions adjacent
to the junctions of the shafts with the epiphyses. The upper and lower ex-
tremities of the femur, and the upper extremity of the tibia, are the common
sites of such fractures; but the upper end of the humerus may also be so
affected. ... A very startling appearance may be observed at this period
in the front of the chest. The sternum, with the adjacent costal cartilages
and a small portion of the contiguous ribs, seems to have sunk bodily back,
en hloc, as though it had been subjected to some violence which had fractured
several ribs in the front and driven them back. Occasionally thickenings of
varying extent may be found on the exterior of the vault of the skull, or
even on some of the bones of the face. . . . Here also must be mentioned a
remarkable eye phenomenon. There develops a rather sudden proptosis of one
eyeball, with puffiness and very slight staining of the upper lid. Within a
day or two the other eye presents similar appearances, though they may be of
less severity. The ocular conjunctiva may show a little ecchymosis, or may
be quite free. With respect to the constitutional symptoms accompanying the
above series of events the most important feature is the profound angemia
which is developed. . . . The anaemia is proportional to the amount of limb
involvement. As the case proceeds, there is a certain earthy-colored or sallow
tint, which is noteworthy in severe cases, and when once this is established
bruise-like echymoses may appear, and more rarely small purpurge. Emacia-
tion is not a marked feature, but asthenia is extreme and suggestive of mus-
cular failure. The temperature is very erratic; it, is often raised for a day
or two, when successive limbs are involved, especially during the tense stage,
but is rarely above 101° or 103°. At other times it may be normal or sub-
normal." If the teeth have appeared the gums may be spongy.
In young children with difficulty in moving the lower limbs, or in whom
paralysis is suspected, the condition should always be looked for. What is
known sometimes as Parrot's disease, or syphilitic pseudo-paralysis, may be
confounded with it. In it the loss of motion is more or less sudden in the
upper or lower limbs, or in both, due to a solution of continuity and separation
of the cartilage at the end of the diaphysis. There are usually crepitation
and much pain on movement.
The essential lesion is a subperiosteal blood extravasation, which causes the
thickening and tenderness in the shafts of the bones. In some instances there
is haemorrhage in the intramuscular tissue.
The prophylaxis is most important. The various proprietary forms of con-
densed milk and preserved foods for infants should not be used. The fresh
cow's milk should be substituted, and a teaspoonful of meat-juice or gravy
may be given with a little mashed potato. Orange-juice or lemon-juice
should be given three or four times a day. Eecovery is usually prompt and
satisfactory.
STATUES LYMPHATICUS. LYMPHATISM. 755
VII. STATUS LYMPHATICUS. LYMPHATISM.
Definition. — A rare condition met with chiefly in children and young per-
sons, in which the lymphatic glands and lymph tissues throughout the body,
the spleen, the thymus, and the lymphoid bone-marrow are in a state of
hyperplasia. These features have been found associated with rickets and with
hypoplasia of the heart and aorta.
The special interest lies in the fact that these pathological conditions have
been met with frequently in cases of sudden death. Paltauf and others of the
Vienna school, who have written extensively on the subject, believe that indi-
viduals with this hyperplasia have lowered powers of resistance, and are par-
ticularly liable to paralysis of the heart.
Anatomical Condition. — (a) Lymph-glands. — The pharyngeal, thoracic,
and abdominal groups are most frequently affected. The cervical, axillary,
and inguinal are less commonly involved, but these glands may show slight
enlargement. The lymphatic structures of the alimentary tract, the tissues
of the tonsils, the adenoid structures in the upper pharynx, and the solitary
and agminated follicles of the small and large intestines are usually much en-
larged. The hyperplasia of the intestinal lymphatic structures may be the
most remarkable, the individual glands standing out like peas.
(&) Spleen. — Enlargement of this organ is usually moderate in degree.
The Malpighian bodies may show very prominently, and when ansemic may
look like large tubercles. The organ is usually soft and hyperffimic.
(c) The THYMUS is enlarged, and may measure as much as 10 cm. in
length. It looks swollen and soft, and on section may exude a milky white
fluid.
(d) The BONE-MAKROW has been found in a state of hyperplasia, and the
yellow marrow of the long bones in young adults, and even in persons between
the ages of twenty and thirty, has been found replaced by red marrow. Among
other associated conditions of this constitutio lympliatica, as it has been called,
are hypoplasia of the heart and aorta and enlargement of the thyroid gland.
In a large number of the cases in children rickets is coincident.
Diagnosis. — The diagnosis of the lymphatic constitution is not always easy.
Enlargement of the superficial glands, with hypertrophy of the tonsils, signs
of slight swelling of the thyroid, dulness over the sternum, with signs of
enlargement of the mesenteric glands, are among the most important fea-
tures. Signs of hypoplasia of the vascular system are still more uncertain,
though Quincke believes that in such instances the left ventricle is dilated and
the peripheral arteries may be much smaller than normal. The subjects have
usually a pale and pasty complexion, and are fat and flabby.
Sudden Death in the Status Lymphaticus. — What has directed the atten-
tion of writers more particularly to this condition is the frequency with which
it has been found in cases of unexpected death from very trifling and inade-
quate causes, as in the case of a death immediately after the preventive inocu-
lation with the antitoxin of diphtheria, and during anathesia in young chil-
dren for trifling operations, as for adenoids or circumcision, etc. Hinkel,
Blake, and others have studied this question with great care. Ether and
chloroform seem equally dangerous in these cases. Cases of sudden death of
756 DISEASES OF THE BLOOD AND DUCTLESS GLANDS.
persons in the water, who have fallen in and, though immediately recovered,
were dead, or who have died suddenly while bathing, are referred by Paltauf
to this condition. And, lastly, there is a large group of cases of sudden death
in children without recognizable cause, in whom post mortem the thymus has
been found enlarged — the so-called "Thymus Tod'' (see under Thymus
Gland). It has also been suggested that certain of the sudden deaths during
convalescence from the infectious fevers are to be referred to this status lym-
phaticus. Escherich thinks that certain measures usually harmless, such as
hydrotherapy, may have an untoward effect in children in this condition of
lymphatism, and adds that tetany and lar3Tigismus may be associated with it.
Two explanations are offered of the sudden death : First, that it is due to
mechanical pressure of the enlarged thjanus on the trachea. In only one of
Blumer's nine cases was there evidence of this. Secondl}^, that it is caused
by a toxaemia, an overproduction of the internal secretion of the thymus.
Blumer has extended this view, and suggests that it is a lymphotoxaemia.
VIII. DISEASES OF THE SUPRARENAL BODIES.
1. Addison's Disease.
Definition. — A constitutional affection characterized by asthenia, muscular
and vascular, irritability of the stomach, and pigmentation of the skin, symp-
toms due, in all probability, to loss of the internal secretion of the adrenal
glands. Tuberculosis of the adrenals is the common anatomical change.
The recognition of the disease is due to Addison, of Guy's Hospital, whose
monograph on The Constitutional and Local Effects of Disease of the Supra-
renal Capsules was published in 1855.
Etiology. — Males are more frequently attacked than females. In Green-
how's analysis of 183 cases 119 were males and 64 females. A majority of
the cases occur between the twentieth and the fortieth year. A congenital
case has been described in which the skin had a yellow-gray tint. The child
lived for eight weeks, and post mortem the adrenals were found to be large
and cystic. Injury such as a blow upon the abdomen or back, and caries of the
spine, have in many cases preceded the attack. The disease is rare in America;
only 17 cases came under my observation.
Morbid Anatomy and Pathology. — There is rarely emaciation or angemia.
Eolleston thus summarizes the condition of the suprarenal bodies in Addison's
disease :
" 1. The fibro-caseous lesion due to tuberculosis — far the commonest con-
dition found. 2. Simple atrophy. 3. Chronic interstitial inflammation lead-
ing to atrophy. 4. Malignant disease invading the capsules, including Addi-
son's case of malignant nodule compressing the suprarenal vein. 5. Blood
extravasated into the suprarenal bodies. 6. No lesion of the suprarenal bodies
themselves, but pressure or inflammation involving the semilunar ganglia.
" The first is the only common cause of Addison's disease. The others,
with the exception of simple atrophy, may be considered as very rare."
The nerve-cells of the semilunar ganglia have been found degenerated and
deeply pigmented, and the nerves sclerotic. The ganglia are not uncommonly
entangled in the cicatricial tissue about the adrenals. The spleen has occa-
sionally been found enlarged ; a persistent enlarged thymus has been found.
DISEASES OF THE SUPRARENAL BODIES. 757
The two chief theories which have heen advanced to explain the disease are :
(a) That it depended upon the loss of function of the adrenals. This was the
view of Addison. The balance of experimental evidence is in favor of the view
that the adrenals are functional glands, which furnish an internal secretion
essential to the normal metabolism, Schafer and Oliver have shown that the
human adrenals contain a very powerful extract, which is not to be obtained
in eases of Addison's disease; they have also studied the toxic effects on ani-
mals of the extracts of the glands. In the cases in which the adrenals have
been found involved without the symptoms of Addison's disease, accessory
glands may have been present ; while in the rare cases in which the symptoms
of the disease have been present with healthy adrenals the semilunar ganglia
and adjacent tissues have been involved in dense adhesions, which may have
interfered readily with the vessels or lymphatics of the glands. On this view
Addison's disease is due to an inadequate supply of the adrenal secretion, just
as myxoedema is caused by loss of function of the thyroid gland. " Whether
the deficiency in this internal secretion leads to a toxic condition of the blood
or to a general atony and apathy is a question which must remain open " (Eol-
leston). (&) That it is an affection of the abdominal sympathetic system,
induced most commonly by disease of the adrenals, but also by other chronic
disorders which involve the solar plexus and its ganglia. According to this
view, it is an affection of the nervous system, and the pigmentation has its
origin in changes induced through the trophic nerves. The pronounced debil-
ity is the outcome of disturbed tissue metabolism, and the circulatory, respira-
tory, and digestive symptoms are due to implication of the pneumogastric
nerves. The changes found in the abdominal sympathetic are held to support
this view, and its advocates urge the occurrence of pigmentation of the skin
in tuberculosis of the peritonasum, cancer of the pancreas, or aneurism of the
abdominal aorta. Bramwell thinks that the symptoms may be in part due to
irritation of the sympathetic and in part to adrenal inadequacy.
Symptoms. — In the words of Addison, the characteristic symptoms are
" anaemia, general languor or debility, remarkable feebleness of the heart's
action, irritability of the stomach, and a peculiar change of color in the
skin,"
The onset is, as a rule, insidious. The feelings of weakness, as a rule,
precede the pigmentation. In other instances the gastro-intestinal symptoms,
the weakness, and the pigmentation come on together. There are a few cases
in the literature in which the whole process has been acute, following a shock
or some special depression. There are three important symptoms :
(1) PiGMENTATioisr OF THE Skin. — TMs, as a rule, first attracts the atten-
tion of the patient's friends. The grade of coloration ranges from a light
yellow to a deep brown, or even black. In typical cases it is diffuse, but always
deeper on the exposed parts and in the regions where the normal pigmentation
is more intense, as the areolae of the nipples and about the genitals ; also wher-
ever the skin is compressed or irritated, as by the waistband. At first it may
be confined to the face and hands. Occasionally it is absent. Patches show-
ing atrophy of pigment, leucoderma, may occur. The pigmentation is found
on the mucous membranes of the mouth, conjunctivae, and vagina. Pig-
mentation of the mucous membrane is not distinctive. It has been found
in chronic stomach troubles, etc. (Fr. Schultze), and is common in the negro.
758 DISEASES OF THE BLOOD AND DUCTLESS GLANDS.
A patchy pigmentation of the serous membranes has often been found. Over
the diffusely pigmented skin there may be little mole-like spots of deeper pig-
mentation, and upon the trunk, particularly on the lower abdomen, they may
be " ribbed " like the sand on the seashore.
(2) Gasteo-intestinal Symptoms. — The disease may set in with attacks
of nausea and vomiting, spontaneous in character. Toward the close there
may be pain with retraction of the abdomen, and even features suggestive of
peritonitis (Ebstein). A marked anorexia may be present. The gastric symp-
toms are variable throughout the course ; occasionally they are absent. Attacks
of diarrhoea are frequent and come on without obvious cause.
(3) Asthenia, the most characteristic feature of the disease, may be
manifested early as a feeling of inability to carry on the ordinary occupation,
or the patient may complain constantly of feeling tired. The weakness is
specially marked in the muscular and cardio-vascular systems. There may be
an extreme degree of muscular prostration in an individual apparently well
nourished, whose muscles feel firm and hard. The cardio-vascular asthenia
is manifest in a feeble, irregular action of the heart, which may come on in
paroxysms, in attacks of vertigo, or of syncope, in one of which the disease
may prove fatal. The blood-pressure is low, falling to 70 or 80 mm. of Hg.
Headache is a frequent symptom ; convulsions occasionally occur. Pain in the
back may be an early and important symptom.
Anaemia, a symptom specially referred to by Addison, is not common. In
a majority of the patients the blood-count is normal. McMunn has described
an increase in the urinary pigments, and a pigment has been isolated of very
much the same character as the melanin of the skin.
The mode of termination is either by syncope, which may occur even early
in the disease, by gradual progressive asthenia, or by the development of tuber-
culous lesions. In two cases I have known a noisy delirium with urgent
dyspnoea to precede the fatal event.
Diagnosis. — Pigmentation of the skin is not confined to Addison's disease.
The following are the conditions which may give rise to an increase in the
pigment :
(1) Abdominal growths — tubercle, cancer, or lymphoma. In tuberculosis
of the peritonseum pigmentation is not uncommon.'^
(3) Pregnancy, in which the discoloration is usually limited to the face,
the so-called masque des femmes enceintes. Uterine disease is a common cause
of a patchy melasma. v
(3) Hcemocliromatosis, associated with hypertrophic cirrhosis, pigmenta-
tion of the skin, and diabetes. More commonly in overworked persons of con-
stipated habit and with sluggish livers there is a patchy staining about the
face and forehead. ^
(4) The vagabond's discoloration, caused by the irritation of lice and
dirt, which may reach a very high grade, and has sometimes been mistaken
for Addison's disease. y
(5) In rare instances there is deep discoloration of the skin in melanotic
cancer, so deep and general that it has been confounded with melasma supra-
renale. J
(6) In certain cases of exophthalmic goitre abnormal pigmentation occurs,
as noted by Drummond and others.
DISEASES OF THE SUPRARENAL BODIES. 759
(7) In a few rare instances the pigmentation in scleroderma may be
general and deep,
(8) In the face there may be an extraordinary degree of pigmentation due
to innumerable small black comedones. If not seen in a very good light,
the face may suggest argyria. Pigmentation of an advanced grade may occur
in chronic ulcer of the stomach and in dilatation of the organ.
(9) Argyria could scarcely be mistaken, and yet I was consulted in a case
in which the diagnosis of Addison's disease had been made by several good
observers.
(10) Arsenic when taken for many months may cause a most intense pig-
mentation of the skin.
(11) With arterio-sclerosis and chronic heart-disease there may be marked
melanoderma.
(12) In pernicious angemia the pigmentation may be extreme, most com-
monly due to the prolonged administration of arsenic.
(13) There is a form of deep pigmentation, usually in women, which per-
sists for years without change and without any special impairment of health.
I have met with two cases; in one the pigmentation was a little more leaden
than is usual in Addison's disease; in both the condition had lasted some
years.
In any case of unusual pigmentation these various conditions must be
sought for; the diagnosis of Addison's disease is scarcely justifiable without
the asthenia. In many instances it is difficult early in the disease to arrive
at a definite conclusion. The occurrence of fainting fits, of nausea, and gas-
tric irritability are important indications. As the lesion of the capsules is
almost always tuberculous, in doubtful cases the tuberculin test may be used.
In two of my cases, robust, healthy men with pigmentation and gastric symp-
toms, the reaction was obtained.
Prognosis. — The disease is usually fatal. The cases in which the bronzing
is slight or does not occur run a more rapid course. There are occasionally
acute cases which, with great weakness, vomiting, and diarrhcea, prove fatal
in a few weeks. In a few cases the disease is much prolonged, even to six or
ten years. In rare instances recovery has taken place, and periods of improve-
ment, lasting many months, may occur.
Treatment. — When there is profound asthenia the patient should be con-
fined to bed, as fatal syncope may at any time occur. In three of my cases
death was sudden. Arsenic and strychnia are useful tonics. For the diar-
rhoea large doses of bismuth should be given ; for the irritability of the stom-
ach, creasote, hydrocyanic acid, ice, and champagne. The diet should be
light and nutritious. Many patients thrive best oh a strict milk diet.
Treatment hy Suprarenal Extract. — E. W. Adams has analyzed 97 cases.
In 7 the condition grew worse, in 3 cases of transplantation death was attrib-
uted to the treatment. In 43 there was no effect noticed. In 31 there was
temporary improvement; in 16 the relief seemed permanent. In two of our
cases there was marked improvement; in one all the severe symptoms disap-
peared, and the patient died of an acute infection, which apparently had noth-
ing to do with the disease. The adrenals were found sclerotic. The gland
may be given raw or partially cooked or in a glycerin extract. Tabloids of the
dried extract are given, one grain of which corresponds to fifteen of the gland.
760 DISEASES OF THE BLOOD AND DUCTLESS GLANDS.
Three of the tabloids may be given daily. Operation has been suggested, but
has not been carried out on any undoubted case.
2. Other Diseases of the Suprarenal Capsules.
Adrenalitis, Acute Hcemorrhagic. — The lesion resembles that of acute pan-
creatitis, hfemorrhage and necrosis in varying proportions. The clinical picture
is very complex. The onset is sudden with pain and vomiting, profound
prostration and death in a few days. In other cases convulsions occur, or
there may be a profound myasthenia, acute or subacute. Sudden death has
occurred. In children the disease may be associated with purpura, cutaneous
and visceral. The symptoms are believed to be due to acute or subacute
adrenal insufficiency. The diagnosis is not often made during life. The
white line, the anaemic vascular skin reflex, described by Sergent as of diag-
nostic value, is too common to be of much import.
Hypertrophy. — In chronic nephritis and arterio-sclerosis adenoma or dif-
fuse hyperplasia of the glands has been found, which some have attributed to
hyperadrenalism — an overactivity of the antitoxic and angiotonic functions
of the gland. In children tumor or hypertrophy has been found associated
with remarkable precocity and development of the sexual organs.
Tumors. — Primary growths are rare, secondary are not uncommon. The
former are usually mistaken for kidney tumors. There is a special type of
malignant growth in children characterized by rapid growth, diffuse infiltra-
tion of the liver, and great distention of the abdomen without ascites or jaun-
dice (Pepper tertius) ; and Eobert Hutchison has described a remarkable
syndrome in children of adrenal tumor, exophthalmos and cranial tumors.
IX. DISEASES OF THE SPLEEN.
The acute swelling in fever, and the chronic enlargement of the organ in
paludism, leuksemia, cirrhosis of the liver, and heart-disease have been fully
described, but there remain several conditions to which brief reference may
be made.
1. Movable Spleen.
Movable or wandering spleen is seen most frequently in women the sub-
jects of enter optosis. It may be present without signs of displacement of
other organs. It may be found accidentally in individuals who present no
symptoms whatever. In other cases there are dragging, uneasy feelings in the
back and side. All grades are met with, from a spleen that can be felt com-
pletely below the margin of the ribs to a condition in which the tumor-mass
impinges upon the pelvis; indeed, the organ has been found in an inguinal
hernia ! In the large majority of all cases the spleen is enlarged. Sometimes
it appears that the enlargement has caused relaxation of the ligaments; in
other instances the relaxation seems congenital, as movable spleens have been
found in different members of the same family. Possibly traumatism may
account for some of the cases. Apart from the dragging, uneasy sensations
and the worry in nervous patients, wandering spleen causes very few serious
symptoms. Torsion of the pedicle may produce a very alarming and serious
condition, leading to great swelling of the organ, high fever, or even to
DISEASES OF THE SPLEEN. 761
necrosis. A young woman was admitted to my colleague Kelly's ward with
a tumor supposed to be ovarian, but which proved to be a wandering, moder-
ately enlarged spleen. She was transferred to the medical ward, where she
had suddenly very great pain in the abdomen, a large swelling in the left flank,
and much tenderness. Halsted operated and found an enormously enlarged
spleen in a condition of necrosis, adherent to the adjacent parts and to the
abdominal wall. He laid it open freely, and large necrotic masses of spleen
tissue discharged for some time. She made a good recovery.
The diagnosis of a wandering spleen is usually easy unless the organ be-
comes fixed and is deformed by adhesions and perisplenitis. The shape of the
organ and the sharp margin with the notches are the points to be specially
noted.
The treatment of the condition is important. Occasionally the organ may
be kept in position by a properly adapted belt and a pad under the left costal
margin. Eemoval of the displaced organ has been advised and carried out in
many cases, and nowadays it is not a very serious operation. It is, however,
as a rule unnecessary. In 2 cases of enlarged spleen under my care, with great
mobility, causing much discomfort and uneasiness, Halsted completely relieved
the condition by replacing the spleen, packing it in position with gauze, and
allowing firm adhesions to take place. Both these patients were seen more
than eighteen months after the operation and the organ had remained in
position.
2. EUPTURE OF THE SpLEEN".
This is of interest in connection with the spontaneous rupture in cases of
acute enlargement during typhoid fever or malaria, which is very rare. Eup-
ture of a malarial spleen may follow a blow, or a fall, or an exploratory punc-
ture. In India and in Mauritius rupture of the spleen is stated to be very
common. Fatal haemorrhage may follow puncture of a swollen spleen with a
hypodermic needle. Occasionally the rupture results from the breaking of an
infarct or of an abscess. The symptoms are those of haemorrhage into the
peritonasum, and the condition demands immediate laparotomy.
3. Infaect and Abscess of the Spleen.
Emboli in the splenic arteries causing infarcts may be either infective or
simple. They are seen most frequently in ulcerative endocarditis and in septic
conditions. Infarcts may also follow the formation of thrombi in the branches
of the splenic artery in cases of fever. They are not very infrequent in
typhoid. In a few instances the infarcts have followed thrombosis in the
splenic veins. They are chiefly of pathological interest. The infarct of the
spleen may be suspected in cases of septicasmia or pyemia when there is pain
in the splenic region, tenderness on pressure, and slight swelling of the organ ;
on several occasions I have heard a well-marked peritoneal friction rub. Occa-
sionally in the infective infarcts large abscesses are formed, and in rare
instances the whole organ may be converted into a sac of pus.
Tumors of the spleen^ hydatid and other cysts of the organ, and gummata
are rare conditions of anatomical interest. In Hodgkin's disease the organ
may be enlarged and smooth, or irregular from the presence of nodular tumors.
50
762 DISEASES OF THE BLOOD AND DUCTLESS GLANDS.
4. Splenomegaly, Splenic Anemia, Banti's Disease,
Angemia may be associated with many conditions in which the spleen is
enlarged — in leukaemia, in pernicious anaemia, in Hodgkiij!s_ disea^, in cir-
rhosis of the liver, particularly of the hypertrophic type, and in the syjhilitic
^orm, and in chronic malaria. But apart from all these, and apart from the
forms of tropical splenomegaly already considered, are the conditions which
have been grouped under the names primitive splenomegaly, splenic angemia,
and Banti's disease. Though the clinical picture may be very similar, it seems
impossible to classify them all as one disease. The following groups of cases
may be described:
1. Banti's disease, with its three stages: (a) simple splenomegaly, which_
may persist for years, without anaemia or with perhaps only a low color index;
(&) severe anemia of a secondary type with pigmentation of the skin and a_
marked tendency to hasmatemesis ; (c) finally jaundice supervenes and ascites.
The chronicity, the great enlargement of the spleen, and the secondary anaemia
are the most striking features. In most cases a chronic hyperplasia of the
organ has been found; in a few an extraordinary endothelial hyperplasia,
which Gaucher described as a chronic endothelioma. In a small number of
cases. Dock, Deve, and others have reported a remarkable sclerosis of the por-
tal vessels, with thromboses and obliteration; but whether this is primary or
secondary has not yet been determined. The cause of the disease is unknown.
It may be a chronic infective process, the chief seat of which is in the spleen,
where the poisons cause the endothelial proliferation. That the spleen itself
is at fault appears probable from the prompt relief which follows removal of
the organ. In three of five cases which I have seen, permanent recovery has
followed splenectomy.
2. There are two family forms of splenomegaly; in one the children
attacked present marked constitutional disturbances — dwarfing of stature,
clubbing of the fingers, infantilism, pigmentation of the skin, and sometimes
enlargement of the liver. This is the variety described by Collier, Bovaid,
Brill, and Frederick Taylor. In the other, the Minkowski type, the spleno-
megaly is associated with a congenital jaundice, but the health of the patient
is not disturbed. Though jaundice is present, there is no bile coloring matter
in the urine — an acholuric icterus.
In Banti's disease removal of the spleen offers the best chance of perma-
nent relief. Armstrong's recent statistics give 72 per cent of recoveries.
Arsenic and the X-rays appear to have very little influence.
5. Splenomegalic Polycythemia with Cyanosis (Vaquez's Disease).
A condition in which with an enlarged spleen and cyanosis there is an
extraordinary increase of the red blood-corpuscles, up to 9-13 millions per
c.mm. Headache, giddiness, and constipation are the common symptoms. The
patients may present a curious brick-red color, or when it is cold an extreme
degree of cyanosis. It is a chronic affection, lasting many years. In the
few post-mortems which have been performed the bone-marrow has been found
in a state of extreme hyperplasia, and it has been suggested that the disease
is the red-blood counterpart of leuksemia — an erythrocythsemia or erythraemia.
DISEASES OF THE THYROID GLAND. 763
In the Quarterly Journal of Medicine, October, 1908, and January, 1909,
Dr. Parkes Weber gives a full critical digest of the subject, which is one
of great clinical and pathological interest. Polyglobulism without splenic
enlargement occurs in many other conditions, particularly in congenital heart-
disease and after residence at high altitudes. With primary tuberculosis of
the spleen there has also been associated polyglobulism and cyanosis.- But
apart from all these conditions there is probably a well-defined disease of
unknown etiology with the above-mentioned characters.
X. DISEASES OF THE THYROID GLAND.
1. Congestion.
At puberty, in girls, often at the onset of menstruation, the gland enlarges ;
in certain women the neck becomes fuller at each menstruation, and it was
an old idea that the gland enlarged at or after defloration. The slight enlarge-
ment at puberty may persist for months and cause uneasiness, but as a rule
it disappears completely. I do not remember a single instance in which the
goitre has remained, though of course such a possibility has to be considered.
From mechanical causes, as tight collars, repeated crying, or prolonged use of
the voice, the gland may swell for a short time.
•
2. Acute Thyeoiditis.
Earely primary, it is almost always a complication of one of the acute
infections, typhoid fever, scarlet fever, diphtheria, pneumonia, rheumatic fever,
or mumps. The whole gland may be involved, or only one lobe. There is
swelling, pain on pressure, and very soon redness over the affected part. It
may resolve or go on to suppuration. The entire gland may be destroyed and
myxoedema follow, as in a case reported by Shields. Basedow's disease has fol-
lowed the acute thyroiditis of typhoid fever.
3. Goitre.
Definition. — Hypertrophy of the thyroid gland, occurring sporadically or
endemically.
Sporadic goitre is not uncommon, and is confined almost exclusively to
women. In girls at puberty slight enlargement of the gland is very common,
and it may persist for a year or longer ; in rare instances the enlargement per-
sists.
The following varieties may be distinguished: (a) Parenchymatous, in
which the enlargement is general and the follicles, usually newly formed,
contain a gelatinous colloid material, (h) Vascular, in which the en-
largement is chiefly due to dilatation of the blood-vessels without the
new formation of glandular tissue, (c) Cystic goitre, in which the en-
larged gland is occupied by large cysts, the walls of which often undergo cal-
cification.
Endemic goitre is rare in the United States and Canada. The endemic
centres referred to in Barton's monograph (1819) and in Hirsch's Geograph-
ical Pathology no longer exist. It is most prevalent about the eastern end of
Lake Ontario and in Michigan (Dock), and in parts of the province of Que-
764 DISEASES OF THE BLOOD AND DUCTLESS GLANDS.
bee ; and of late 5^ears there appears to have been an increase in the cases.
In Great Britain it is still met with in a few localities, as in Derbyshire — ^the
Derbyshire neck; and it is very common in the upper Thames valle}^. In
Switzerland and parts of France and Italy it is very prevalent, occurring
alone or in association with cretinism. In parts of Central Asia there are
towns, such as Khokand in Turkestan, in which a large proportion of the
population have goitre or cretinism. Eussian troops stationed there may have
goitres within a few months.
In schools and garrisons there have been remarkable otitbreaks of acute
goitre in epidemic form, lasting a few months, and disappearing, in schools,
after the holidays. In one instance 161 boys among 350, and 245 girls among
381, were attacked (Guillaume).
Symptoms. — The enlargement may be uniform or affect only one lobe,
or the isthmus alone. When small, a goitre causes no inconvenience. When
large, it may compress the trachea, causing dyspnoea, or may pass iDcneath the
sternum and compress the veins. These, however, are exceptional circum-
stances, and in a large proportion of all cases no serious symptoms are noted.
The affection usually comes under the care of the surgeon. Sudden death
occasionally occurs in large bronchoceles. In some instances it may be difficult
to determine the cause, and it has been thought to be associated with pressure
on the vagi. I have reported an instance in which it resulted from hgemor-
rhage into the gland and into the adjacent tissues. The blood passed into the
cellular tissues of the neck and under the sternum, covering the aorta and
pericardium. In regions in which goitre prevails the drinking-water should
be boiled. Change of locality is sometimes followed by cure. The medicinal
treatment is very unsatisfactory. Iodine and various counterirritants exter-
nally, iodide of potash, ergot, and many other drugs are recommended by
writers. The thyroid extract has been used with success in a few cases. If
the organ progressively enlarges and causes great disfigurement or inconven-
ience, operation should be advised.
4. Tumors of the Thyroid.
These are very varied, (a) Adenomata, either simple or malignant.
The latter may form extensive metastases. A case is reported by Hayward
in which growths resembling thyroid tissue occurred in the lungs and
various bones of the body, (h) Cancer, of which several forms have been
described, (c) Sarcoma. All of these have a surgical rather than a medical
interest.
Aberrant and Accessory Thyroids. — Anywhere from the root of the tongue
to the arch of the aorta small fragments of thyroidal tissue have been found.
In the mediastinum they may form large tumors, and in the pleura an acces-
sory cystic thyroid may fill the upper half of one pleural cavity or even the
entire side (F. A. Packard). The Ungual thyroid is not uncommon, vary-
ing in size from a hemp seed to a pea, usually free in the deep muscles
of the tongue, or attached to the hyoid bone. When enlarged the lingual
goitre may form a tumor of considerable size. The true thyroid has been
absent, and removal of the lingual goitre has been followed by myxoedema
(Storrs).
DISEASES OF THE THYROID GLAND. 765
5. Exophthalmic Goitre.
(Graves's, Basedow's, or Parry's Disease.)
Definition. — A disease characterized by exophthalmos, enlargement of the
thyroid, and functional disturbance of the vascular system. It is very possibly
caused by disturbed function of the thyroid gland (hyperthyroidism).
Historical Note. — In the posthumous writings of Caleb Hillier Parry
(1835) is a description of 8 cases of Enlargement of the Thyroid Gland in
Connection with Enlargement or Palpitation of the Heart. In the first case,
seen in 1786, he also described the exophthalmos: '"'The eyes were protruded
from their sockets, and the countenance exhibited an appearance of agitation
and distress, especially in any muscular movement." The Italians claim that
Flajani described the disease in 1800. I have not been able to see his original
account, but Moebius states that it is meagre and inaccurate, and bears no
comparison with that of Parry. If the name of any physician is to be asso-
ciated with the disease, undoubtedly it should be that of the distinguished old
Bath physician. Graves described the disease in 1835 and Basedow in 1840.
Etiology. — The disease is more frequent in women than in men. Of 200
cases tabulated by Eshner, there were 161 females. The age of onset is usually
from the twentieth to the thirtieth year. It is sometimes seen in several mem-
bers of the same family. Worry, fright, and depressing emotions precede the
development of the disease in a number of cases.
The disease is regarded by some as a pure neurosis, in favor of which is
urged the onset after a profound emotion, the absence of lesions, and the
cure which has followed in a few cases after operations upon the nose. Others
believe that it is caused by a central lesion in the medulla oblongata. In
support of this there is a certain amount of experimental evidence, and in
a few autopsies changes have been found in the medulla. Of late years the
view has been urged, particularly by Moebius and by Greenfield, that exoph-
thalmic goitre is primarily a disease of the thyroid gland (hyperthyrea) , in
antithesis to myxcedema (athyrea). The clinical contrast between these two
diseases is most suggestive — the increased excitability of the nervous system,
the flushed, moist skin, the vascular erythism in the one; the dull apathy,
the low temperature, slow pulse, and dry skin of the other. The changes in
the gland in exophthalmic goitre are, as shown by Greenfield, those of an organ
in active evolution — viz., increased proliferation, with the production of newly
formed tubular spaces and absorption of the colloid material which is replaced
by a more mucinous fluid (Bradshaw Lecture, 1893). The thyroid extract
given in excess produces symptoms not unlike those of Parry's disease — tachy-
cardia, tremor, headache, sweating, and prostration. Beclere has recently
reported a case in which exopthalmos developed after an overdose. Use of
the thj^roid extract usually aggravates the symptoms of exophthalmic goitre.
The most successful line of treatment has been that directed to diminish the
bulk of the goitre. These are some of the considerations which favor the view
that the symptoms are due to disturbed function of the thyroid gland, prob-
ably to hypersecretion of certain materials, which induce a sort of chronic
intoxication. Myxcedema may develop in the late stages, and there are tran-
sient oedema and in a few eases scleroderma, which indicate that the nutrition
766 DISEASES OF THE BLOOD AND DUCTLESS GLANDS.
of the skin is involved. Persistence of the thymns is almost the rule (Hector
Mackenzie), but its significance is unknown.
Symptoms. — Acute and chronic forms may be recognized. In the acute
form the disease may arise with great rajDidity. In a patient of J. H. Lloyd's,
of Philadelphia, a woman, aged thirty-nine, who had been considered perfectly
healthy, but whose friends had noticed that for some time her eyes looked
rather large, was suddenly seized with intense vomiting and diarrhoea, rapid
action of the heart, and great throbbing of the arteries. The eyes were promi-
nent and staring and the thyroid gland was found much enlarged and soft.
The gastro-intestinal symptoms continued, the pulse became more rapid, the
vomiting was incessant, and the patient died on the third day of the illness.
Only the abdominal and thoracic organs could be examined and no changes
were found. Two rapidly fatal cases occurred at the Philadelphia Hospital,
one of which, under F. P. Henry's care, had marked cerebral symptoms. The
acute cases are not always associated with delirium. In a case reported by
Sutcliff death occurred within three months from the onset of the s}anptoms,
owing to repeated and uncontrollable vomiting. More frequently the onset is
gradual and the disease is chronic. There are four characteristic symptoms
of the disease — exophthalmos, tachycardia, enlargement of the thyroid, and
tremor.
Tachtcaedia. — Eapid heart action is only one of a series of remarkable
vascular phenomena in the disease. The pulse-rate at first may be not more
than 95 or 100, but when the disease is established it may be from 1-10 to
160, or even higher. Irregularity is not common, except toward the close. In
a Avell-developed case the visible area of cardiac pulsation is much increased,
the action is heaving and forcible, and the shock of the heart-sounds is well
felt. The large arteries at the root of the neck throb forcibly. There is
visible pulsation in the peripheral arteries. The capillary pulse is readily
seen, and there are few diseases in which one may see at times with greater
distinctness the venous pulse in the veins of the hand. The throbbing pulsa-
tion of the arteries may be felt even in the finger tips. Vascular erythema is
common — the face and neck are flushed and there may be a wide-spread ery-
thema of the body and limbs. On auscultation murmurs are usually heard
over the heart, a loud apex systolic and loud bruits at the base and over the
manubrium. The sounds of the heart may be very intense. In rare instances
they may be heard at some distance from the patient; according to Graves,
as far as four feet. Attacks of acute dilatation of the heart may occur with
dyspnoea, cough, and a frothy bloody expectoration.
Exophthalmos^ which may be unilateral, usually follows the vascular dis-
turbance. It is readily recognized by the protrusion of the balls, and partly by
the fact that the lids do not completely cover the sclerotics, so that a rim of
white is seen above and below the cornea. The protrusion may become very
great and the eye may even be dislocated from the socket, or both eyes may be
destroyed by panophthalmitis, a condition present in one of Basedow's cases.
The vision is normal. Graefe noted that when the eyeball is moved downward
the upper lid does not follow it as in health. This is known as Graefe's sign.
The palpebral aperture is wider than in health, owing to spasm or retraction of
the upper lid (Stellwag's sign). The patient winks less frequently than in
health. Moebius has called attention to the lack of convergence of the two
DISEASES OF THE THYROID GLAND. ' 767
eyes. Changes in the pupils and in the optic nerves are rare. Pulsation of the
retinal arteries is common.
Enlargement of the thyroid commonly occurs with the exophthalmos.
It may be general or in only one lobe, and is rarely so large as in ordinary
goitre. The vessels are usually much dilated, and the whole gland may be
seen to pulsate. A thrill may be felt on palpation and on auscultation a loud
systolic murmur, or more commonly a bruit de diable. A double murmur is
common and is pathognomonic (Guttmann).
Tremor is the fourth cardinal symptom, and was really first described by
Basedow. It is involuntary, fine, about eight to the second. It is of great
importance in the diagnosis of the early cases.
Among other symptoms are anaemia, emaciation, and slight fever. At-
tacks of vomiting and diarrhoea may occur. The latter may be very severe
and distressing, recurring at intervals. The greatest complaint is of the forci-
ble throbbing in the arteries, often accompanied with unpleasant flushes of
heat and profuse perspirations.
Erythematous flushing is common. Pruritus may be a severe and per-
sistent symptom. Multiple telangiectases have been described. Solid, infil-
trated oedema is not uncommon. It may be transitory, A remarkable myx-
cedematous state may supervene. Pigmentary changes are very common. They
may be patchy or generalized. Hydrocystoma may occur, and the coexistence
of scleroderma and Graves's disease has been frequently noticed. Irritability
of temper, change in disposition, and great mental depression have been de-
scribed. An important complication is acute mania, in which the patient may
die in a few days. Weakness of the muscles is not uncommon, particularly a
feeling of " giving way " of the legs. If the patient holds the head down and
is asked to look up without raising the head, the forehead remains smooth and
is not wrinkled, as in a normal individual (Joffroy). A feature of interest
noted by Charcot is the great diminution in the electrical resistance, which
may be due to the saturation of the skin with moisture owing to the vaso-motor
dilatation (Hirt). Bryson has noted the fact that the chest expansion may be
greatly diminished. The emaciation may be extreme. Glycosuria and albu-
minuria are not infrequent complications. True diabetes may occur.
The course of the disease is usually chronic, lasting several years. After
persisting for six months or a year the symptoms may disappear. There are
remarkable instances in which the symptoms have come on with great inten-
sity, following fright, and have disappeared again in a few days. A certain
proportion of the cases get well, but when the disease is well advanced recov-
ery is rare.
Diagnosis. — Few diseases are so easily recognized. The difficulty is with
the partially developed forms, formes frustes, which are not uncommon. The
nervous state, the tremor, and tachycardia may be the only features, or there
may be slight swelling of the thyroid with tremor alone. The greatest diffi-
culty arises in the cases of hysterical tremor with rapid heart action.
Treatment. — (a) The disease is serious enough to warrant strong measures
systematically carried out ; much valuable time is lost in trying various rem-
edies. The patient should be in bed, at absolute rest, and see very few persons.
To quiet the heart's action the ice-bag may be continuously applied through
the day, and veratrum viride, aconite, or strophanthus given in full doses.
768 ' DISEASES OF THE BLOOD AND DUCTLESS GLANDS. '
Ergot, belladonna, phosphate of soda, small doses of opium, and many other
remedies are recommended, and in some instances I have seen benefit from
the belladonna and the phosphate of soda. Electricity may be helpful.
(&) Serum Therapy. — Two methods are employed: feeding with the milk
of dethyroidized goats, introduced by Lanz, which is obtainable as a substance
called rodagen. Good results have been reported by Mackenzie and others.
Beebe, on the other hand, uses the serum of animals into which human thyroid
extract has been injected. Excellent results have been obtained, but the
method has the danger associated with the use of foreign sera.
(c) Surgical Treatment. — Eemoval of part of the thyroid gland offers
the best hope of permanent cure. It is remarkable with what rapidity all the
symptoms may disappear after partial thyroidectomy. A second operation
may be necessary in severe cases. The results obtained by the brothers Mayo
and by Kocher give a remarkable percentage of recoveries. The operation
under cocaine may be done with safety when the condition of the heart and
the extreme tachycardia do not contraindicate it. Tying of the arteries and
exothyropexia are also recommended. Excision of the superior cervical ganglia
of the sympathetic has one beneficial result, viz., the production of slight
ptosis, which obviates the staring character of the exophthalmos.
Marked benefit has followed the use of the X-rays in a few cases.
6, Myx(edema (Atkyrea).
Definition. — A constitutional affection, due to the loss of function of the
thyroid gland. The disease, which was described by Sir William Gull as a
cretinoid change, and later by Ord, is characterized clinically by a myxoedema-
tous condition of the subcutaneous tissues and mental failure, and anatom-
ically by atrophy of the thyroid gland.
Clinical Forms. — Three groups of cases may be recognized — cretinism,
myxoedema proper, and operative myxcedema. To Felix Semon is due the
credit of recognizing that these were one and the same condition and all due
to loss of function of the thyroid.
Cketixism. — This remarkable impairment of nutrition follows absence or
loss of function of the thyroid gland, either congenital or appearing at any
time before puberty. There is remarkable retardation of development, reten-
tion of the infantile state, and an extraordinary disproportion between the
different parts of the body. Two forms are recognized, the sporadic and the
endemic. In the sporadic form the gland may be congenitally absent, it may
be atrophied after one of the specific fevers, or the condition may develop
with goitre. Since we have learned to recognize the disease it is surprising
how many cases have been reported. In Great Britain the disease is not
uncommon, and many cases have been reported.
The condition is rarely recognized before the infant is six or seven
months old. Then it is noticed that the child does not grow so rapidly and
is not bright mentally. The tongue looks large and hangs out of the mouth.
The hair may be thin and the skin very dry. Usually by the end of the
first year and during the second year the signs become very marked. The
face is large, looks bloated, the eyelids are puffy and swollen; the alse nasi
are thick, the nose looks depressed and flat. Dentition is delayed, and the
DISEASES OF THE THYROID GLAND. 769
teeth which appear decay early. The abdomen is swollen, the legs are thick
and short, and the hands and feet are undeveloped and pudgy. The face is
pale and sometimes has a waxy, sallow tint. The fontanelles remain open;
there is much muscular weakness, and the child can not support itself. In the
supraclavicular regions there are large pads of fat. The child does not develop
mentally ; there are various grades of idiocy and imbecility.
A very interesting form is that in which, after the child has thriven and
developed until its fourth or fifth year, or even later, the symptoms begin
after a fever, in consequence of an atrophy of the gland. Parker suggests for
this variety the name juvenile myxoedema.
Endemic cretinism occurs under local conditions, as yet unknown, in asso-
ciation with goitre. It is met with chiefly in Switzerland and parts of Italy
and France.
The diagnosis is very easy after one has seen a case or good illustrations.
Infants a year or so old sometimes become flabby, lose their vivacity, or show
a protuberant abdomen and lax skin with slight cretinoid appearance. These
milder forms, as they have been termed, are probably due to transient func-
tional disturbance in the gland. There is rarely any difficulty in recognizing
the different other types of idiocy. The condition known as foetal rickets,
achondroplasia^ or chondrodystrophia fcetalis, is more likely to be mistaken
for cretinism. The children which survive birth grow up as a remarkable
form of dwarfs, characterized by shortness of the limbs ( micro melia) and
enormous enlargement of the articulations, due to hyperplasia of the carti-
laginous ends of the bones. Infantilism — the condition characterized by a
preservation in the adult of the exterior form of infancy with the non-appear-
ance of the secondary sexual chargtcters — could scarcely be mistaken for
cretinism.
Myxcedema of Adults (Gull's Disease). — In this, women are very much
more frequently affected than men — in a ratio of 6 to 1. The disease may
affect several members of a family, and it may be transmitted through the
mother. In some instances there has been first the appearance of exophthalmic
goitre. Though occurring most commonly in women, it seems to have no
special relation to the catamenia or to pregnancy ; the symptoms of myxoedema
may disappear during pregnancy or may develop post partum. Myxoedema
and exophthalmic goitre may occur in sisters. It is not so common in Amer-
ica as in England. In sixteen years I saw only 10 cases in Baltimore, 7 of
which were in the hospital. C. P. Howard has collected 100 American cases,
of which 86 were in women. The symptoms of this form, as given by Ord,
are marked increase in the general bulk of the body, a firm, inelastic swell-
ing of the skin, which does not pit on pressure; dryness and roughness,
which tend, with the swelling, to obliterate in the face the lines of ex-
pression; imperfect nutrition of the hair; local tumefaction of the skin and
subcutaneous tissues, particularly in the supraclavicular region. The phys-
iognomy is altered in a remarkable way: the features are coarse and broad,
the lips thick, the nostrils broad and thick, and the mouth is enlarged.
Over the cheeks, sometimes the nose, there is a reddish patch. There is a
striking slowness of thought and of movement. The memory becomes de-
fective, the patients grow irritable and suspicious, and there may be head-
ache. In some instances there are delusions and hallucinations, leading to
770 DISEASES OF THE BLOOD AND DUCTLESS GLANDS.
a final condition of dementia. The gait is heavy and slow. The tempera-
ture may- be below normal. The functions of the heart, lungs, and abdom-
inal organs are normal. Haemorrhage sometimes occurs. Albuminuria is
sometimes present, more rarely glycosuria. Death is usually due to some
intercurrent disease, most frequently tuberciilosis (Greenfield). The thyroid
gland is diminished in size and may become completely atrophied and con-
verted into a fibrous mass. The subcutaneous fat is abundant, and in one
or two instances a great increase in the mucin has been found. The larynx
is also involved.
The course of the disease is slow but progressive, and extends over ten or
fifteen years. A condition of acute and temporary myxoedema may develop in
connection with enlargement of the thyroid in young persons. Myxoedema
may follow exophthalmic goitre. In other instances the symptoms of the two
diseases have been combined. I have reported a case in which a young man
became bloated and increased in weight enormously during three months, then
had tachycardia with, tremor and active delirium, and died within six months
of the onset of the symptoms.
Operative Mtxcedema ; Cachexia Strumipeiva. — Horsley, in a series of
interesting experiments, showed that complete removal of the thyroid in mon-
keys was followed by the production of a condition similar to that of myx-
oedema and often associated with spasms or tetanoid contractures, and followed
by apathy and coma. When the monkeys were kept warm myxoedema was
averted, and, instead of an acute myxoedema, the animals had a condition
which closely resembled cretinism. An identical condition may follow extirpa-
tion of the thyroid in man. Kocher, of Bern, found that after complete extir-
pation a cachectic condition followed in many cases, the symptoms of which
are practically identical with those of myxoedema. The disease follows only
a certain number of total and a much smaller proportion of partial removals
of the thyroid gland. Of 408 cases, in 69 the operative myxoedema occurred.
It has been thought that if a small fragment of the thyroid remains, or if
there are accessory glands, which in animals are very common, these symptoms
do not develop. It is possible that, in men, in the cases of complete removal,
the accessory fragments subserve the function of the gland. Operative myx-
oedema is very rare in America. A few years ago I was able to find only two
cases, one of which, McOraw's, referred to in previous editions of this work, has
since been cured.
The diagnosis of myxoedema is easy, as a rule. The general aspect of the
patient — ^the subcutaneous swelling and the pallor — suggests Bright's disease,
which may be strengthened by the discovery of tube-casts and of albumin in
the urine; but the solid character of the swelling, the exceeding dryness of
the skin, the yellowish-white color, the low temperature, the loss of hair, and
the dull, listless mental state should suffice to differentiate the two conditions.
In dubious cases not too much stress should be laid upon the supraclavicular
swellings. There may be marked fibro-fatty enlargements in this situation in
healthy persons, the supraclavicular pseudo-lipomata of Verneuil.
Treatment. — The patients suffer in cold and improve greatly in warm
weather. They should therefore be kept at an even temperature, and should,
if possible, move to a warm climate during the winter months. Eepeated warm
baths with shampooing are useful. Our art has made no more brilliant
DISEASES OF THE THYMUS GLAND. 771
advance than in the cure of these disorders due to disturbed function of the
thyroid gland. That we can to-day rescue children otherwise doomed to help-
less idiocy — that we can restore to life the hopeless victims of myxoedema —
is a triumph of experimental medicine for which we are indebted very largely
to Victor Horsley and to his pupil Murray. Transplantation of the gland was
first tried ; then Murray used an extract subcutaneously. Hector Mackenzie in
London and Howitz in Copenhagen introduced the method of feeding. We
now know that the gland, taken either fresh, or as the watery or glycerin ex-
tract, or dried and powdered, is equally efficacious in a majority of all the cases
of myxoedema in infants or adults. Many preparations are now on the mar-
ket, but it makes little difference how the gland is administered. The dried
powdered gland and the glycerin extract are most convenient. It is well to
begin with the powdered gland, 1 grain three times a day, of the Parke-Davis
preparation, or one of the Burroughs and Welcome tablets. The dose may be
increased gradually until the patient takes 10 or 15 grains in the day. In
many cases there are no unpleasant symptoms; in others there are irritation
of the skin, restlessness, rapid pulse, and delirium; in rare instances tonic
spasms, the condition to which the term thyroidism is applied. The results,
as a rule, are most astounding — unparalleled by anything in the whole range
of curative measures. Within six weeks a poor, feeble-minded, toad-like cari-
cature of humanity may be restored to mental and bodily health. Loss of
weight is one of the first and most striking effects ; one of my patients lost over
30 pounds within six weeks. The skin becomes moist, the urine is increased,
the perspiration returns, the temperature rises, the pulse-rate quickens, and the
mental torpor lessens. Ill effects are rare. Two or three cases with old heart
lesions have died during or after the treatment; in one instance a temporary
condition of Graves' disease was induced.
The treatment, as Murray suggests, must be carried out in two stages —
one, early, in which full doses are given until the cure is effected ; the other,
the permanent use of small doses sufficient to preserve the normal metabolism.
In the cases of cretinism it seems to be necessary to keep up the treatment
indefinitely. I have seen several instances of remarkable relapse follow the
cessation of the use of the extract.
XI. DISEASES OF THE THYMUS GLAND.
The functions of this gland are unknown. It is a suggestive fact that Bau-
mann found in it minute quantities of a compound containing iodine. It has
been thought that its internal secretion has an infiuence in combating infective
agents. Friedleben's estimate of the weight of the organ at birth — 13
grammes — is stated by Dudgeon to be too high. He puts it at 7.10 grammes.
The largest in his series occurred in a child aged five months, 47 grammes.
At the ninth month the gland weighs 20 grammes, and at the second year
25 to 30.
The organ, after reaching its largest size about the end of the second year,
gradually wastes, until at the time of puberty it is a mere fatty remnant,
in which, however, there are " traces of its original structure in the form of
small masses of thymus corpuscles, and even of concentric corpuscles "
(Quain). A complete consideration of the affections of this gland is to be
772 DISEASES OF THE BLOOD AND DUCTLESS GLANDS.
found in Friedleben's remarkable monograph, Die Physiologie der Thymus-
driise, 1858. The following are the most important conditions:
I. Persistence of the organ after the fifteenth year, met with occasionally,
but under circumstances so varied that a satisfactory explanation can not be
offered. The existence of the gland may be determined by the presence of
an area of dulness along the left sternal border.
II. Hypertrophy of the Thymus. — The size of the gland varies widely, so
that it is difficult to define exactly the limits between persistence and enlarge-
ment. The condition is of interest from three standpoints: (a) The supposed
occurrence of thymic asthma, due to pressure from the enlarged gland. A
number of observers have attributed the symptoms of laryngismus stridulus
to pressure exerted by the enlarged thymus. Many German writers consider
thymic asthma identical with the laryngismus stridulus of English authors,
who, as a rule, have laid no stress whatever on the association. There can be,
I think, no question that the ordinary laryngismus seen in rickety children is a
convulsive affection and is not the result of compression. But a very greatly
enlarged thymus may seriously hamper the structures within the thorax.
Jacobi, in his monograph on the gland, states that in an infant of eight months
the distance between the manubrium sterni and the vertebral column is 2.3
cm., a space which he thinks might be completely filled by an enlarged and
congested thjaiius. Siegel's case also points to the possibility of this com-
pression. A boy aged two and a half years had had for two weeks cough
and bronchial rales with dyspnoea, which was more or less constant with noc-
turnal exacerbations. Laryngismus stridulus was diagnosed. Tracheotomy
was performed shortly after admission without relief, but when subsequently
the anterior mediastinum was opened from above by extending the incision
from the tracheotomy wound, a piece of the thymus as large as a hazel-nut
appeared with each inspiration. The gland was drawn up with forceps and
fastened by three stitches to the fascia over the sternum. The child rested
quietly after the operation, had no dyspnoea, and made a complete recovery
(Berl. klin. Woch., 1896, No. 40). From a child aged two months (dyspnoeic
from the eighth day) Konig removed a portion of the thymus, leaving the
substernal part. These are cases that go far to disprove Friedleben's dictum —
es gieht l-ein Asthma thymicum. Warthin has considered the whole question
very thoroughly in his exhaustive article on the Thymus in my " System of
Medicine," Vol. IV.
(h) Thymus Enlargement and Sudden Death. — In considering the ques-
tion of the so-called lymphatic constitution, with which an enlarged th5Tiius
is usually associated, we have spoken of the occurrence of sudden death. Two
groups of cases are met with in the literature : First, such instances as those
described by Grawitz, Jacobi, and others, in which young infants have been
either found dead in bed or have been attacked suddenly with dyspnoea, have
become cyanotic and died in a few minutes. In such cases the thymus has
been found greatly enlarged, and death has been thought to be directly due
either to pressure on the air-passages, pressure on the pneumogastric (causing
spasm of the glottis), or pressure on the great vessels. To the second group
belong the cases in adults which have been described of late by ISTordmann,
Paltauf, Ohlmacher, and others, in which the sudden death has occurred under
such conditions as anaesthesia or while bathing. In a number of these cases
INFANTILISM. 773
not only has the thymus been found enlarged, but the spleen and lymphatic
tissues generally. The question is one of considerable medico-legal interest,
and has been spoken of under Lymphatism.
Eolleston reports a case of sudden death after signs of cardiac failure last-
ing for only twenty minutes, in which there was hyperplasia of a persistent
thymus. The gland with the trachea weighed 11 ounces.
(c) Atrophy of the Thymus. — The condition may be primary, found acci-
dentally in a child without any other pathological changes except a wasting
or marasmus. To this association Ruhrah has called special attention. The
secondary atrophy is common in tuberculosis and other chronic maladies.
(d) Thymus Gland and Exophthalmic Goitre. — That there is some asso-
ciation between these conditions is urged on two grounds : First, the per-
sistence of the gland in Graves' disease. W. W. Ord and Hector Mackenzie
state that it has been found enlarged in all the cases examined at St. Thomas's
Hospital. Hektoen concludes from a very thorough study of the question
that the coexistence is more than accidental. Secondly, the good results which
are stated to follow the feeding of the thymus gland in Graves' disease are held
to bear out the idea that the enlargement during life is compensatory. The
general conclusion, however, reached by Hector Mackenzie and by Kinnicutt
is that the thymus feeding has at best only slight influence upon Graves'
disease.
It is interesting to note in connection with the question of enlarged
thymus and sudden death that two of Hale White's cases of exophthalmic
goitre died suddenly, and autopsy showed no reasonable cause of death.
Among other conditions with which enlarged thymus has been associated
may be mentioned epilepsy (Ohlmacher).
III. Other Morbid Conditions of the Thymus. — Hcemorrhages are not un-
common, and are found particularly in children who have died of asphyxia.
Tumors of the gland, particularly sarcoma and lympho-sarcoma, have been
frequently described. Many mediastinal tumors originate in the remnants of
the thymus. Dermoid tumors and cysts have also been met with. Tubercu-
losis of the gland, chiefly in the form of miliary nodules, is well described in
Jacobi's monograph. There is a well-authenticated case in which it was pri-
mary. Focal necroses in diphtheria have also been described by Jacobi.
Abscess oe the Thymus. — The condition described by Dubois, in which
there were fissure-like cavities filled with a purulent fluid, and supposed to be
present chiefly in the subjects of congenital syphilis, is stated by Chiari to be
a post-mortem softening, which opinion Dudgeon's observations confirm. In
one case Jacobi found a small gumma.
XII. INFANTILISM.
Associated with loss or perversion of the internal secretions there is a
remarkable condition known as infantilism, characterized by the persistence of
the physical features of childhood after the period of puberty has passed.
There is an arrest of development of the sexual organs and an absence of
the secondary sexual characteristics — namely, the changes in the figure, as seen
in the adult, the presence of the facial, pubic, and axillary hair, and the laryn-
geal enlargement with the corresponding changes in the voice. There is usu-
774 DISEASES OF THE BLOOD AND DUCTLESS GLANDS.
ally a corresponding failure in tlie mental development, so that the individual
remains a child in mind as well as in body. Various types have been de-
scribed. The following are the most important :
1. Myxoedematous Infantilism. — This has already been described under
cretinism. Here there is no question that the thyroid inadequacy is respon-
sible for the condition.
2. The Lorain Type of Infantilism. — " In this variety, the figure is so
small that, at first sight, it looks like that of a child. When the patient is
stripped, however, his outlines are seen to be those of an adult and not those
of childhood. The head is proportionately small and the trunk well-formed;
for the shoulders are broad compared to the hips, and the bony prominences
and the muscles stand out distinctly. We have before us a miniature man (or
woman, as the case may be), and not one who has retained the characteristics
of childhood beyond the proper time. There is indeed no growth of facial,
pubic, or axillary hair, yet the genital organs, although small, are well shaped
and quite large enough for the size of the body. The intelligence in both
sexes is generally normal.^' ( Jolm Thomson.) By far the most potent cause
in producing this form is hereditary syphilis. Alcoholism in the parents and
consanguinity are also mentioned. The various causes leading to malnutrition
play an important part — insufficient food, chronic poisoning by tobacco, lead,
and mercury. Defective arterial development is suggested by some writers as
an important factor.
B3Tom Bramwell has described a condition of retarded development asso-
ciated with chronic diarrhoea, which he has called pancreatic infantilism. One
patient gained remarkably in two years under the use of the pancreatic extract,
and it is suggested that pancreatic internal secretion was defective.
3. Ateliosis: Progeria. — Under these terms, signifying continuous youth
and premature old age, Hastings Gilford has described interesting types of
dwarfs. There are two varieties of ateliosis; the asexual, an infantilism with-
out any connection with cretinism, sj^philis, or congenital heart disease. It
is often more a delay than an arrest of development. The sexual form is the
" Tom Thumb " variety of dwarf. There is a similar delay in development
until puberty, when the sexual organs mature and the body becomes set or
stereotyped as a miniature man or woman.
Progeria is a remarkable condition in which, with infantilism, as shown in
stature and proportion, there is premature decay, as shown in the facial appear-
ance, attitude, loss of hair, muscular and fatty emaciation, and post mortem
extensive atheroma of arteries and degenerative (senile) changes in the viscera.
SECTION IX.
DISEASES OF THE OIEOULATORY SYSTEM.
A. DISEASES OE THE PERICARDIUM.
I. PERICARDITIS.
Peeicarditis is the result of infective processes, primary or secondary, or
arises by extension of inflammation from contiguous organs.
Etiology. — Primary, so-called idiopathic, inflammation is rare ; but it has
been met with in children without any evidence of rheumatism or of any local
or general disease. Certain of these cases are tuberculous.
Pericarditis from injury usually comes under the care of the surgeon in
connection with the primary wound. The trauma may be from within, due
to the passage of a foreign body — a needle, a pin, or a bone — through the
oesophagus — a variety exceedingly common in cows and horses.
Secondary: (a) Most frequently in connection with rheumatism. The
percentage given by different authors ranges from thirty to seventy. In our
330 cases of rheumatic fever (Johns Hopkins Hospital) pericarditis occurred
in twenty — practically 6 per cent. The articular trouble may be slight or,
indeed, the disease may be associated with acute tonsillitis in rheumatic sub-
jects. Certain of the so-called idiopathic cases have their origin in an acute
tonsillitis. The pericarditis may precede the arthritis, (h) In septic pro-
cesses; in the acute necrosis of bone and in puerperal fever it is not uncom-
mon, (c) In tuberculosis, in which the disease may be primary or part of a
general involvement of the serous sacs or associated with extensive pulmonary
disease, (d) In the fevers. Not infrequent after scarlatina; it is rare in
measles, small-pox, typhoid fever, and diphtheria. In pneumonia it is not
uncommon, occurring in 31 among 665 in my clinic (J. A. Chatard). Post
mortem there were 184 cases with 39 instances of pericarditis. It is most
frequent in double pneumonia, and in our series with disease of the right side,
if only one lung was involved. Pericarditis sometimes complicates chorea; it
was present in 19 of 73 autopsies which I collected; in only 8 of these was
arthritis present, (e) Terminal pericarditis. In gout, in chronic Bright's
disease — pericardite hrightique of the French — ^in arterio-sclerosis, in scurvy,
in diabetes, and in chronic illness of all sorts a latent pericarditis is common
and is usually overlooked.
(/) By Extension. — In pleuro-pneumonia it forms a serious complication,
and was present in 5 cases of 100 post mortems (Montreal General Hospital).
It is most often met with in the pleuro-pneumonia of children and of
775
776 DISEASES OF THE CIRCULATORY SYSTEM.
alcoholics. With, simple pleurisy it is rare. In ulcerative endocarditis, puru-
lent m3-ocarditis, and in aneurism of the aorta pericarditis is occasionally
found. It may also follow extension of the disease from the mediastinal
glands, the ribs, sternum, vertebras, and even from the abdominal viscera. The
ordinary pus cocci, the pneumococcus, and the tubercle bacillus are the chief
organisms met with in acute pericarditis.
Pericarditis occurs at all ages. Cases have been reported in the foetus.
In the new-born it may result from septic infection through the navel.
Throughout childhood the incidence of rheumatism and scarlet fever makes
it a frequent affection, whereas late in life it is most often associated with
tuberculosis, Bright's disease, and gout. Males are somewhat more frequently
attacked than females. Climatic and seasonal influences have been mentioned
by some writers. The so-called epidemics of pericarditis have been outbreaks
of pneumonia with this as a frequent complication.
Of 100 consecutive cases at the Boston City Hospital, in 54 the exudate
was dry, in 41 serous, in 4 haemorrhagic, and in 5 purulent. Thirty-four cases
showed signs of old valvular disease; rheumatism was a factor in 51; pneu-
monia in 18; and in 7 chronic nephritis. Of the 100 cases 43 died (Sears).
Acute Fibeinous Peeicarditis.
This, the most common and benign form, is distinguished by the small
amount of exudate which coats the surface in a thin layer.
It may be partial or general. In the mildest grades the membrane looks
lustreless and roughened, due to the presence of a thin fibrinous sheeting,
which can be lifted with the knife, showing beneath an injected or ecchymotic
serosa. As the fibrinous sheeting increases in thickness the constant move-
ment of the adjacent surfaces gives to it sometimes a ridge-like, at others a
honeycombed appearance. With more abundant fibrinous exudation the mem-
branes present an appearance resembling buttered surfaces which have been
drawn apart. The fibrin is in long shreds, and the heart presents a curiously
shaggy appearance — the so-called hairy heart of old writers — cor villosum.
In mild grades the subjacent muscle looks normal, but in the more pro-
longed and severe eases there is myocarditis, and for 2 or 3 mm. beneath the
visceral layer the muscle presents a pale, turbid appearance. Many of these
acute cases are tuberculous and the granulations are easily overlooked in a
superficial examination.
There is usually a slight amount of fluid entangled in the meshes of fibrin,
but there may be very thick exudate without much serous effusion.
Symptoms. — Simple plastic pericarditis, like simple endocarditis, presents
as a rule no symptoms, and unless sought for there are no objective signs, and
this is the reason why it is so often overlooked, and why in hospitals the dis-
ease is relatively more common in the post-mortem room than in the wards.
Pain is a variable s}Tiiptom, not usually intense, and in this form rarely
excited by pressure. It is more marked in the early stage, and may be
referred either to the pra^cordia or to the region of the xiphoid cartilage.
Instances are recorded of pain of an aggravated and most distressing char-
acter resembling angina. Fever is usually present, but it is not always easy
to say how much depends upon the primary disease, and how much upon the
DISEASES OF THE PERICARDIUM. 777
pericarditis. It is as a rule not high, rarely exceeding 103.5°. In rheumatic
cases hyperpyrexia has been observed.
Physical Signs. — Inspection is negative; palpation may reveal the pres-
ence of a distinct fremitus caused by the rubbing of the roughened pericardial
surfaces. This is usually best marked over the right ventricle. It is not
always to be felt, even when the friction sound on auscultation is loud and
clear. Auscultation: The friction sound, due to the movement of the peri-
cardial surfaces upon each other, is one of the most distinctive of physical
signs. It is double, corresponding to the systole and diastole; but the syn-
chronism with the heart-sounds is not accurate, and the to-and-fro murmur
usually outlasts the time occupied by the first and second sound. In rare
instances the friction is single ; more frequently it appears to be triple in char-
acter— a sort of canter rhythm. The sounds have a peculiar rubbing, grating
quality, characteristic when once recognized, and rarely simulated by endo-
cardial murmurs. Sometimes instead of grating there is a creaking quality —
the bruit de cuir neuf — the new-leather murmur of the French. The peri-
cardial friction appears superficial, very close to the ear, and is usually inten-
sified by pressure with the stethoscope. It is best heard over the right ven-
tricle, the part of the heart which is most closely in contact with the front
of the chest — that is, in the fourth and fifth interspaces and adjacent portions
of the sternum. There are instances in which the friction is most marked at
the base, over the aorta, and at the superior reflection of the pericardium.
Occasionally it is best heard at the apex. It may be limited and heard over a
very narrow area, or it may be transmitted up and down the sternum. There
are, however, no definite lines of transmission as in the endocardial murmur.
An important point is the variability of the sounds, both in position and
quality; they may be heard at one visit and not at another. The maximum
of intensity will be found to vary with position. Friction may be present
with a thin, almost imperceptible, layer of exudate; on the other hand it may
not be present with a thick, buttery layer. The rub may be entirely obscured
by the loud bronchial rales in pneumonia, in which disease pericarditis is not
recognized clinically in more than half the cases, only 13 in 31 cases in my
series. i
Diagnosis. — There is rarely any difficulty in determining the presence of
a dry pericarditis, for the friction sounds are distinctive. The double murmur
of aortic incompetency may simulate closely the to-and-fro pericardial rub.
I recall several instances in which this mistake was made. The constant char-
acter of the aortic murmur, the direction of transmission, the phenomena in
the arteries, and the associated conditions of the disease should be sufficient to
prevent this error.
I have never known an instance in which pericarditis was mistaken for
acute endocarditis, though writers refer to such, and give the differential diag-
nosis in the two affections which so often occur together in children. The
only possible mistake could be made in those rare instances of single soft,
systolic, pericardial friction.
Pleuro-pericardial friction is very common, and may be associated with
endo-pericarditis, particularly in cases of pleuro-pneumonia. It is frequent,
too, in tuberculosis. It is best heard over the left border of the heart, and is
much affected by the respiratory movement. Holding the breath or taking
778 DISEASES OF THE CIRCULATORY SYSTEM.
a deep inspiration may annihilate it. The rhytlim is not the simple to-and-
fro diastolic and systolic, but the respiratory rhythm is superadded, usually
intensifying the murmur during expiration and lessening it on inspiration.
In tuberculosis of the lungs there are instances in which, with the friction,
a loud systolic click is heard, due to the compression of a thin layer of lung
and the expulsion of a bubble of air from a small softening focus or from a
bronchus.
And, lastly, it is not very uncommon, in the region of the apex beat,
to hear a series of fine crepitant sounds, systolic in time, often very dis-
tinct, suggestive of pericardial adhesions, but heard too frequently for this
cause.
Course and Termination. — Simple fibrinous pericarditis never kills, but
it occurs so often in connection with serious affections that we have frequent
opportunities to see all stages of its progress. In the majority of cases the
inflammation subsides and the thin fibrinous laminse gradually become con-
verted into connective tissue, which unites the pericardial leaves firmly to-
gether. A very thin layer may " clear " without leaving adhesions. In other
instances the inflammation progresses, with increase of the exudation, and the
condition is changed from a " dry " to a '^ moist " pericarditis, or the peri-
carditis with effusion.
In a few instances — probably always tuberculous — the simple plastic peri-
carditis becomes chronic, and great thickening of both visceral and parietal
layers is gradually induced.
Pericarditis with Effusion.
Commonly a direct sequence of the dry or plastic pericarditis, of which
it is sometimes called the second stage, this form is found most frequently in
association with acute rheumatism, tuberculosis, and septicaemia, and sets in
usually with the s3rmptoms above described, namely, prsecordial pain, with
slight fever or a distinct chill.
In children the disease may, like pleurisy, come on without local symp-
toms, and, after a week or two of failing health, slight fever, shortness of
breath, and increasing pallor, the physician may find, to his astonishment,
signs of most extensive pericardial effusion. These latent cases are often
tuberculous. W. Ewart has called special attention to latent and ephemeral
pericardial effusions, which he thinks are often of short duration and of
moderate size, with an absence of the painful features of pericarditis. The
effusion may be sero-fibrinous, hsemorrhagic, or purulent. The amount varies
from 200 or 300 ec. to 2 litres. In the cases of sero-fibrinous exudation the
pericardial membranes are covered with thick, creamy fibrin, which may be
in ridges or honeycombed, or may present long, villous extensions. The
parietal layer may be several millimetres in thickness and may form a firm,
leathery membrane. The hgemorrhagic exudation is usually associated with
tuberculous, or with cancerous pericarditis, or with the disease in the aged.
The lymph is less abundant, but both surfaces are injected and often show
numerous htemorrhages. Thick, curdy masses of lymph are usually found in
the dependent part of the sac. In the purulent effusion the fluid has a creamy
consistency, particularly in tuberculosis. In many cases the effusion is really
sero-purulent, a thin, turbid exudation containing flocculi of fibrin.
DISEASES OF THE PERICARDIUM. 779
The pericardial layers are greatly thickened and covered with fibrin. When
tlie fluid is pus, they present a grayish, rough, granular surface. Sometimes
there are distinct erosions on the visceral membrane. The heart muscle in
these cases becomes involved to a greater or less extent, and on section, the
tissue, for a depth of from 2 to 3 mm., is pale and turbid, and shows evi-
dence of fatty and granular change. Endocarditis coexists frequently, but
rarely results from the extension of the inflammation through the wall of
the heart.
Symptoms. — Even with copious effusion the onset and course may be so
insidious that no suspicion of the true nature of the disease is aroused.
As in the simple pericarditis, pain may be present, either sharp and stab-
bing or as a sense of distress and discomfort in the cardiac region. It is more
frequent with effusion than in the plastic form. Pressure at the lower end of
the sternum usually aggravates it. Dyspnoea is a common and important
symptom, one which, perhaps, more than any other, excites suspicion of grave
disorder and leads to careful examination of heart and lungs. The patient is
restless, lies upon the left side or, as the effusion increases, sits up in bed.
Associated with the dyspnoea is in many cases a peculiarly dusky, anxious
countenance. The pulse is rapid, small, sometimes irregular, and may present
the characters known as pulsus paradoxus, in which during each inspiration
the pulse-beat becomes very weak or is lost. These symptoms are due, in great
part, to the direct mechanical effect of the fluid within the pericardium which
embarrasses the heart's action. Other pressure effects are distention of the
veins of the neck, dysphagia, which may be a marked symptom, and irritative
cough from compression of the trachea. Aphonia is not uncommon, owing
to compression or irritation of the recurrent laryngeal as it winds round the
aorta. Another important pressure effect is exercised upon the left lung. In
massive effusion the pericardial sac occupies such a large portion of the antero-
lateral region of the left side that the condition has frequently been mistaken
for pleurisy. Even in moderate grades the left lung is somewhat compressed,
an additional element in the production of the dyspnoea.
Great restlessness, insomnia, and in the later stages low delirium and coma
are symptoms in the more severe cases. Delirium and marked cerebral symp-
toms are associated with the hyperpyrexia of rheumatic cases, but apart from
the ordinary delirium there may be peculiar mental symptoms. The patient
may become melancholic and show suicidal tendencies. In other cases the
condition resembles closely delirium tremens. Sibson, who has specially de-
scribed this condition, states that the majority of such cases recover. Chorea
may also occur, as was pointed out by Bright. Epilepsy is a rare complication
which has occurred during paracentesis.
Physical Signs. — Inspection. — In children the prsecordia bulges and
with copious exudation the antero-lateral region of the left chest becomes
enlarged. A wavy impulse may be seen in the third and fourth interspaces, or
there may be no impulse visible. The intercostal spaces bulge somewhat and
there may be marked oedema of the wall. The epigastrium may be more
prominent. Perforation externally through a space is very rare. Owing to
the compression of the lung, the expansion of the left side is greatly dimin-
ished. The diaphragm and left lobe of the liver may be pushed down and may
produce a distinct prominence in the epigastric region.
780 DISEASES OF THE CIRCULATORY SYSTEM.
Palpation. — A gradual diminution and final obliteration of the cardiac
shock is a striking feature in progressive effusion. The j)osition of the apex
beat is not constant. In large effusions it is usually not felt. In children as
the fluid collects the pulsation may be best seen in the fourth space, but this
may not be the apex itself. Ewart maintains that the position of the apex
beat is unaltered, or even depressed. The pericardial friction may lessen with
the effusion, though it often persists at the base when no longer palpable over
the right ventricle, or may be felt in the erect and not in the recumbent pos-
ture. Fluctuation can rarely, if ever, be detected.
Percussion gives most important indications. The gradual distention of
the pericardial sac pushes aside the margins of the lungs so that a large area
comes in contact with the chest wall and gives a greatly increased percussion
dulness. The form of this dulness is irregularly pear-shaped; the base or
broad surface directed downward and the stem or apex directed ujDward toward
the manubrium. A valuable sign, to which Eotch called attention, is the
absence of resonance in the fifth right intercostal space — the cardio-hepatic
angle. In the left infrascapular area there may be a patch of diminished reso-
nance or even flatness (Ewart).
Auscultation. — The friction sound heard in the early stages may dis-
appear when the effusion is copious, but often persists at the base or at the
limited area of the apex. It may be audible in the erect and not in the recum-
bent posture. With the absorption of the fluid the friction returns. One of
the most important signs is the gradual weakening of the heart-sounds, which
with the increase in the effusion may become so muffled and indistinct as to
be scarcely audible. The heart's action is usually increased and the rhythm
disturbed. Occasionally a systolic endocardial murmur is heard. Early and
persistent accentuation of the pulmonary second sound may be present
(Warthin).
Important accessory signs in large effusion are due to pressure on the left
lung. The antero-lateral margin of the lower lobe is pushed aside and in
some instances compressed, so that percussion in the axillary region, in and
just below the transverse nipple line, gives a modified percussion note, usually
a flat tympany. Variations in the position of the patient may change mate-
rially this modified percussion area, over which on auscultation there is either
feeble or tubular breathing.
Course. — Cases vary extremely in the rapidity with which the effusion
takes place. In every instance, when a pericardial friction murmur has been
detected, the practitioner should first outline with care — ^using the aniline pen-
cil or nitrate of silver — the upper and lateral limits of cardiac dulness, secondly
mark the position of the apex beat, and thirdly note the intensity of the heart-
sounds. In many instances the exudation is slight in amount, reaches a
maximum within forty-eight hours, and then gradually subsides. In other
instances the accumulation is more gradual and progressive, increasing for
several weeks. To such cases the term chronic has been applied. The rapidity
with which a sero-fibrinous effusion may be absorbed is surprising. The possi-
bility of the absorption of a purulent exudate is shown by the cases in which
the pericardium contains semi-solid grayish masses in all stages of calcifica-
tion. With sero-fibrinous effusion, if moderate in amount, recovery is the
rule, with inevitable union, however, of the pericardial layers. In some of the
• DISEASES OF THE PERICARDIUM. 781
septic cases there is a raj)id formation of pus and a fatal result may follow in
three or four days. More commonly, when death occurs with large effusion, it
it not until the second or third week and takes place by gradual asthenia.
Prognosis. — In the sero-fibrinous effusions the outlook is good, and a large
majority of all the rheumatic cases recover. The purulent effusions are, of
course, more dangerous ; the septic cases are usually fatal, and recovery is rare
in the slow, insidious tuberculous forms.
Diagnosis. — Probably no serious disease is so frequently overlooked by the
practitioner. Post-mortem experience shows how often pericarditis is not
recognized, or goes on to resolution and adhesion without attracting notice.
In a case of rheumatism, watched from the outset, with the attention directed
daily to the heart, it is one of the simplest of diseases to diagnose; but. when
one is called to a case for the first time and finds perhaps an increased area
of prtecordial dulness, it is often very hard to determine with certainty whether
or not effusion is present.
The difficulty usually lies in distinguishing between dilatation of the heart
and pericardial effusion. Although the differential signs are simple enough
on paper, it is notoriously difficult in certain cases, particularly in stout per-
sons, to say which of the conditions exists. The points which deserve atten-
tion are:
(a) The character of the impulse, which in dilatation, particularly in
thin-chested people, is commonly visible and wavy.
(h) The shock of the cardiac sounds is more distinctly palpable in dila-
tation.
(c) The area of dulness in dilatation rarely has a triangular form; nor
does it, except in cases of mitral stenosis, reach so high along the left sternal
margin or so low in the fifth and sixth interspaces without visible or palpable
impulse. An upper limit of dulness shifting with change of position speaks
strongly for effusion.
(d) In dilatation the heart-sounds are clearer, often sharp, valvular, or
fcBtal in character; gallop rhythm is common, whereas in effusion the sounds
are distant and muffled.
(e) Earely in dilatation is the distention sufficient to compress the lung
and produce the tympanitic note in the axillary region.
The number of excellent observers who have acknowledged that they have
failed sometimes to discriminate between these two conditions, and who have
indeed performed paracentesis cordis instead of paracentesis pericardii^ is per-
haps the best comment on the difficulties.
Massive (1^ to 2 litre) exudations have been confounded with a pleural
effusion. On more than one occasion the pericardium has been tapped under
the impression that the exudate was pleuritic. The flat tympany in the infra-
scapular region, the absence of well-defined movable dulness, and the feeble,
muffled sounds are indicative points. Followed from day to day there is rarely
much difficulty, but it is different when a patient seen for the first time pre-
sents a large area of dulness in the antero-lateral region of the left chest, and
there is no to-and-fro pericardial friction murmur. Many of the cases have
been regarded as encapsulated pleural effusions.
A special difficulty exists in recognizing the large exudate in pneumonia.
The effusion may be very much larger than the signs indicate, and the involve-
782 DISEASES OF THE CIRCULATORY SYSTEM.
ment of the adjacent lung and pleura is confusing. In at least tkree cases
in our series we should have tapped the sac ; post mortem the effusion was more
than a litre.
The nature of the fluid can not positively be determined without aspira-
tion; but a fairly accurate opinion can be formed from the nature of the
primary disease and the general condition of the patient. In rheumatic cases
the exudation is usually sero-fibrinous ; in septic and tuberculous cases it is
often purulent from the outset; in senile^ nephritic, and tuberculous cases the
exudate may be hfemorrhagic.
Treatment. — The patient should have absolute quiet, mentally and bodily,
so as to reduce to a minimum the heart's action. Drugs given for this pur-
pose, such as aconite or digitalis, are of doubtful utility. Local bloodletting
by cupping or leeches is certainly advantageous in robust subjects, particularly
in the cases of extension in pleuro-pneumonia. The ice-bag is of great value.
It may be applied to the prscordia at first for an hour or more at a time,
and then continuously. It reduces the frequency of the heart's action and'
seems to retard the progress of an effusion. Blisters are not indicated in the
early stage.
When effusion is present, the following measures to promote absorption
may be adopted: Blisters to the prsecordia, a practice not so much in vogue
now as formerly. It is surprising, however, in some instances, how quickly
an effusion will subside on their application. Purges and iodide of potassium
are of doubtful utility. The diet should be light, dry, and nutritious. The
action of the kidneys may be promoted by the infusion of digitalis and potas-
sium acetate.
With an effusion, so soon as signs of serious impairment of the heart occur,
as indicated by dyspnoea, small rapid pulse, dusky, anxious countenance,
paracentesis, or incision of the pericardium, should be performed. With the
sero-fibrinous exudate, such as commonly occurs after rheumatism, aspiration
is sufficient; but when the exudate is purulent, the pericardium should be
freel}' incised and freely drained. The puncture may be made in the fourth
or fifth interspace, in or outside the nipple line. In large effusions the peri-
cardium can be readily reached without danger by thrusting the needle upward
and backward close to the costal margin in the left costo-xiphoid angle. The
results of paracentesis of the pericardium have so far not been satisfactory.
With an earlier operation in many instances and a more radical one in others
— incision and free drainage, not aspiration, when the fluid is purulent —
the percentage of recoveries will be greatly increased. Eepeated tapping may
be needed. One case of tuberculous effusion, tapped three times, recovered
completely and was alive three years afterward.
Cheoxic Adhesive Peeicaeditis {Adherent Pericardium).
The remote prognosis in pericarditis is very variable. A large majority of
these cases get well and have no further trouble, but in young persons serious
results sometimes follow adhesions and thickening of the layers. As Sequira
has pointed out. the danger is here directly in proportion to the amount of dila-
tation and weakening of the pericardium in consequence of the inflammation.
The loss of the firm support afforded to the heart by the rigid fibrous bag
DISEASES OF THE PERICARDIUM. 783
in which it is enclosed, is the important factor. Tliere are two groups of
cases of adherent pericardium :
(a) Simple adhesion of the peri- and epicardial layers, a common sequence
of pericarditis, met with post mortem as an accidental lesion. It is not
necessarily associated with disturbance in the function of the heart, which in
a large proportion of the cases is neither dilated nor hypertrophied.
(&) Adherent pericardium with chronic mediastinitis and union of the
outer layer of the pericardium to the pleura and to the chest walls. This
constitutes one of the most serious forms of cardiac disease, particularly in
early life, and may lead to an extreme grade of hypertrophy and dilatation of
the heart. The peritoneum may be involved with perihepatitis, cirrhosis, and
ascites (Pick's disease).
Symptoms. — The symptoms of adherent pericardium are those of hyper-
trophy and dilatation of the heart, and later of cardiac insufficiency. G. D.
Head in a careful study of 59 cases divides them into a small silent group
with no symptoms, a larger group with all the features of cardiac disease, and
a third group, comprising 11 cases in his series in which the features were
hepatic.
Diagnosis. — The following are important points in the diagnosis: Inspec-
tion.— A majority of the signs of value come under this heading, (a) The
prgecordia is prominent and there may be marked asymmetry, owing to the enor-
mous enlargement of the heart. ( & ) The extent of the cardiac impulse is greatly
increased, and may sometimes be seen from the third to the sixth interspaces,
and in extreme cases from the right parasternal line to outside the left nipple,
(c) The character of the cardiac impulse. It is undulatory, wavy, and in
the apex region there is marked systolic retraction, (d) Diaphragm phe-
nomena. J. F. H. Broadbent has called attention to a very valuable sign in
adherent pericardium. When the heart is adherent over a large area of the dia-
phragm there is with each pulsation a systolic tug, which may be communicated
through the diaphragm to the points of its attachment on the wall, causing a
visible retraction. This has long been recognized in the region of the seventh
or eighth rib in the left parasternal line, but Dr. Broadbent called attention
to the fact that it was frequently best seen on the left side behind, between
the eleventh and twelfth ribs. This is a very valuable and quite common sign,
and may sometimes be very localized. One difficulty is that, as A. W. Tallant
has pointed out, it may occur in thin-chested persons with great hypertrophy
of the heart. Sir William Broadbent calls attention also to the fact that owing
to the attachment of the heart to the central tendon of the diaphragm this
part does not descend with inspiration, during which act there is not the visible
movement in the epigastrium, (e) Diastolic collapse of the cervical veins, the
so-called Friedreich's sign. This is not of much moment.
Palpation. — The apex beat is fixed, and turning the patient on the left side
does not alter its position. This I have found, however, somewhat uncertain.
On placing the hand over the heart there is felt a diastolic shock or reboimd,
which some have regarded as the most reliable of all signs of adherent peri-
cardium.
Percussion. — The area of cardiac dulness is usually much increased. In
a majorit}^ of instances there are adhesions between the pleura and the peri-
cardium, and the limit of cardiac dulness above and to the left may be fixed
784 DISEASES OF THE CIRCULATORY SYSTEM.
and is uninfluenced l\y deep inspiration. This, too, is an uncertain sign, inas-
much as there may be close adhesions between the pleura and the pericardium
and between the pleura and the chest wall, which at the same time allow a
very considerable degree of mobility to the edge of the lung.
Auscultation. — The phenomena are variable and uncertain. In the cases
in children with a history of rheumatism, endocarditis has usually been pres-
ent. Even in the absence of chronic endocarditis, when the dilatation reaches
a certain grade there are murmurs of relative insufficiency, which, as in one
ease I have recorded, may be present not only at the mitral but also at the tri-
cuspid and pulmonary orifices. Theodore Fisher has called attention to the
fact that there may be a well-marked presystolic murmur in connection with
adherent pericardium. Occasionally the layers of the pericardium are united
in places by strong fibrous bands, 5-7 mm. long by 3-5 mm. wide. In one
such case Drasche heard a remarkable whirring, systolic murmur with a twang-
ing quality.
The pulsus paradoxus, in which during inspiration the pulse- wave is small
and feeble, is sometimes present, but it is not a diagnostic sign of either simple
pericardial adhesion or of the cicatricial mediastino-pericarditis.
Chronic adhesive pericarditis and mediastinitis may be associated with
proliferative peritonitis, perihepatitis, and perisplenitis — the polyserositis, sim-
ple or tuberculous — in which condition ascites may recur for months, or even
for years.
Cardiohjsis. Brauer's operation, has been proposed for this condition and
has been helpful in a few cases. Four or five centimetres of the fourth, fifth,
and sixth left ribs with a couple of centimetres of the corresponding cartilages
are resected, by wMch means the heart's action is less embarrassed. It is a
justifiable procedure in selected cases — in, for example, a child with a very
large, tumultuously acting heart, with much bulging of the chest.
II. OTHER AFFECTIONS OF THE PERICARDIUM.
(1) Hydropericardium.— The pericardial sac contains post mortem a few
cubic centimetres of clear, citron-colored fluid. In connection with general
dropsy, due to kidney or heart disease, more commonly the former, the
effusion may be excessive, adding to the embarrassment of the heart and the
lungs, particularly when the pleural cavities are the seat of similar transuda-
tion. There are rare instances in which effusion into the pericardium occurs
after scarlet fever with few, if any, other dropsical symptoms. Hydropericar-
dium is frequently overlooked.
In rare cases the serum has a milkj' character — chylopericardimn.
(2) Hsemopericardiuin. — This condition is met with in aneurism of the
first part of the aorta, of the cardiac wall, or of the coronary arteries, and in
rupture and wounds of the heart. Death usually follows before there is time
for the production of symptoms other than those of rapid heart-failure due to
compression. In rupture of the heart the patient may live for many hours or
even days with symptoms of progressive heart-failure, dyspnoea, and the
physical signs of effusion.
In the pericarditis of tuberculosis, of cancer, of Bright's disease, and of
old people, the inflammatory exudate is often blood-stained.
DISEASES OF THE HEART. 785
(3) Pneumopericardium. — This is an excessively rare condition, of which
Walter James was able to collect in 1903 only 38 cases. I have met with but
one instance, from rupture of a cancer of the stomach. Perforation of the sac
occurred in all but 5, in which the gas bacillus was the possible cause, as in
Nicholl's case at the Royal Victoria Hospital, Montreal, this organism was iso-
lated. Seven cases were due to perforation of the oesophagus and eight to pene-
trating wounds from without. • The physical signs are most characteristic.
A tympany replaces the normal pericardial flatness. On auscultation there is
a splashing, gurgling, churning sound, called by the French hruit de moulin.
This was described in 19 of the cases collected by James. Of the 38 cases, 26
died.
(4) Calciied Pericardium. — This remarkable condition may follow peri-
carditis, particularly the suppurative and tuberculous forms; occasionally it
extends from the calcified valves. It may be partial or complete. Of 59 cases
collected by A. E. Jones, in 38 there were no cardiac symptoms. Adherent
pericardium was diagnosed in one case. Jones's careful study shows that the
condition is usually latent and unrecognized.
B. DISEASES OF THE HEABT.
I. ENDOCARDITIS.
Inflammation of the lining membrane of the heart is usually confined to
the valves, so that the term is practically synonymous with valvular endo-
carditis. It occurs in two forms — acute, characterized by the presence of
vegetations with loss of continuity or of substance in the valve tissues ; chronic,
a slow sclerotic change, resulting in thickening, puckering, and deformity.
Acute Endocarditis.
This occurs in rare instances as a primary, independent affection; but
in the great majority of cases it is an accident in various infective processes,
so that in reality the disease does not constitute an etiological entity.
For convenience of description we speak of a simple or benign, and a
malignant, ulcerative, or infective endocarditis, between which, however, there
is no essential anatomical difference, as all gradations can be traced, and they
represent but different degrees of intensity of the same process.
Etiology. — Simple Endocaeditis does not constitute a disease of itself,
but is invariably found with some other affection. In 330 cases of rheumatic
fever at the Johns Hopkins Hospital there were 110 cases of endocarditis.
Bouillaud first emphasized the frequency of the association of simple endo-
carditis with rheumatic fever. Before him, however, the association had been
noticed. Possibly it is nothing in the disease itself, but simply an altered
state of the fluid media — a reduction perhaps of the lethal influences which
they normally exert — permitting the invasion of the blood by certain micro-
organisms. Tonsillitis, which in some forms is regarded as a rheumatic affec-
tion, may be complicated with endocarditis. Of the specific diseases of child-
hood it is not uncommon in scarlet fever, while it is rare in measles and
51
786 DISEASES OF THE CIRCULATORY SYSTEM.
cliieken-pnx. In diphtheria simple endocarditis is rare. In small-pox it is not
common. In tyj^hoid fever it occurred six times among 1.500 cases.
In pneumonia both simple and malignant endocarditis are common. In
100 autopsies in this disease made at the Montreal General Hospital there were
5 instances of the former. Among 61 cases of endocarditis studied bacterio-
logically in Welch's laboratory, pneumococci were found in 21 (Marshall).
Of 517 fatal cases of acute endocarditis, 115 were in connection with pneu-
monia— 22.3 per cent (E. F. Wells). Acute endocarditis is by no means rare
in phthisis. I found it in 12 cases in 216 post mortems.
In chorea simple warty vegetations are found on the valves in a large
majority of all fatal cases, in 62 of 73 cases collected by me. There is no
disease in which, post mortem, acute endocarditis has been so frequently found.
And, lastly, simple endocarditis is met with in diseases associated with loss
of flesh and progressive debility, as cancer, and such disorders as gout, dia-
betes, and Bright's disease.
A very common form is that which occurs on the sclerotic valves in old
heart-disease — the so-called recurring endocarditis.
Maligxaxt or ixfective E^^)OCARDITIS is met with: (a) As a primary
disease of the lining membrane of the heart or of its valves.
(&) As a secondary affection in acute rheumatism, pneumonia, in various
specific fevers, in septic processes of all sorts, and most frequently of all as
an infection on old sclerotic valves. In a majorit}' of all cases it is a local
process in an acute infection. Congenital lesions are very prone to the severer
t}^es of endocarditis, particularly affections of the orifice of the pulmonary
artery and the margins of the imperfect ventricular septum (C. Eobinson).
The existence of a primary endocarditis has been doubted ; but there
are instances in which persons previously in good health, without any history of
affections with which endocarditis is usually associated, have been attacked
with s}Tnptoms resembling severe tj^hus or typhoid. In one case which I saw,
death occurred on the sixth day and no lesions were found other than those of
malignant endocarditis.
The simple endocarditis of rheumatic fever or of chorea rarely progresses
into the malignant form. In only 21: of 209 cases the spnptoms of severe endo-
carditis arose in the progress of acute or subacute rheumatism. Of all acute
diseases complicated with severe endocarditis pneumonia probably heads the
list. Gonorrhcea is a much more common cause than has been supposed.
There have been at least ten instances in my wards.
The affection may complicate erysipelas, septicsemia (from whatever cause),
and puerperal fever. Malignant endocarditis is very rare in tuberculosis,
typhoid fever, and diphtheria.
It has been stated by many -^Titers that endocarditis occurs in malaria.
With the unusual facilities for the study of this disease which I have had in the
past sixteen years I have not yet met with an instance. In dysentery, in small-
pox, and in scarlet fever, with which simple endocarditis is not infrequently
complicated, the malignant form is extremely rare.
Morbid Anatomy of Simple and Malignant Endocarditis. — Simple endo-
CAEDiTis is characterized by the presence on the valves or on the lining mem-
brane of the chambers of minute vegetations, ranging from 1 to 4 mm. in
diameter, with an irregular and fissured surface, giving to them a warty or
DISEASES OF THE HEART. 787
verrucose appearance. Often these little cauliflower-like excrescences are
attached by very narrow pedicles. They are more common on the left side of
the heart than the right, and occur on the mitral more often than on the aortic
valves. The vegetations are upon the line of closure of the valves — i. e., on the
auricular face of the auriculo-ventricular valves, a little distance from the
margin, and on the ventricular side of the sigmoid valves, festooned on either
half of the valve from the corpus Arantii. It is rare to see any swelling or
macroscopic evidence of infiltration of the endocardium in the neighborhood
of even the smallest of the granulations, or of redness, indicative of distention
of the vessels, even when they occur upon valves already the seat of sclerotic
changes, in which capillary vessels extend to the edges. With time the vegeta-
tions may increase greatly in size, but in what may be called simple endo-
carditis the size rarely exceeds that mentioned above.
The earliest vegetations consist of elements derived from the blood, and
are composed of blood platelets, leucocytes, and fibrin in varying proportions.
At a later stage they appear as small outgrowths of connective tissue. The
transition of one form into the other can often be followed. The process con-
sists of a proliferation of the endothelial cells and the cells of the subendo-
thelial layer which gradually invade the fresh vegetation, and ultimately
entirely replace it. The blood-cells and fibrin undergo disintegration and
gradually they are removed. The whole process has received the name of
" organization." Even when the vegetation has been entirely converted into
connective tissue it is often found at autopsy to be capped with a thin layer
of fibrin and leucocytes.
Micro-organisms are generally, even if not invariably, found associated
with the vegetations. They tend to be entangled in the granular and fibrillated
fibrin or in the older ones to cap the apices.
Subsequent Changes. — (1) The vegetations may become organized and
the valve restored to a normal state ( ?). (2) The process may extend, and a
simple may become an ulcerative endocarditis. (3) The vegetations may be
broken off and carried in the circulation to distant parts. (4) The vegeta-
tions become organized and disappear, but they initiate a nutritive change
in the valve tissue which ultimately leads to sclerosis, thickening, and de-
formity. The danger in any case of simple endocarditis is not immediate,
but remote, and consists in this perversion of the normal processes of nutri-
tion which results in sclerosis of the valves.
A gradual transition from the simple to a more severe affection, to which
the name malignant or ulcerative endocarditis has been given, may be
traced. Practically in every case of ulcerative endocarditis vegetations are
present. In this form the loss of substance in the valve is more pronounced,
the deposition — thrombus formation — from the blood is more extensive, and
the micro-organisms are present in greater number and often show increased
virulence. Ulcerative endocarditis is often found in connection with heart
valves already the seat of chronic proliferative and sclerotic changes.
In this form there is much loss of substance, which may be superficial and
limited to the endocardium, or, what is more common, it involves deeper struc-
tures, and not very infrequently leads to perforation of a valve, the septum,
or even of the heart itself.
Upon microscopical examination the affected valve shows necrosis, with
788 DISEASES OF THE CIRCULATORY SYSTEM.
more or less loss of substance; the tissue is devoid of preserved nuclei and
presents a coagulated appearance. Upon it a mixture of blood platelets, fibrin
— granular or fibrillated — and leucocytes enclosing masses of micro-organisms
are met with. The subjacent tissue often shows sclerotic thickening and
always infiltration with exuded cells.
Paets Affected. — The following figures, taken from my Goulstonian lec-
tures, give an approximate estimate of the frequency with which in 209 cases
different parts of the heart were affected in malignant endocarditis: Aortic
and mitral valves together, in 41; aortic valves alone, in 53; mitral valves
alone, in 77; tricuspid in 19; the pulmonary valves in 15; and the heart walls
in 33. In 9 instances the right heart alone was involved, in most cases the
auriculo-ventricular valves.
Mural endocarditis is seen most often at the upper part of the septum
of the left ventricle. ;N"ext in order is the endocarditis of the left auricle on
the postero-external wall. The vegetations may extend, as in a case in my
wards, along the intima of the pulmonary artery into the hilum of the lung.
A common result of the ulceration is the production of valvular aneurism.
In three-fourths of the cases the affected valves present old sclerotic changes.
The process may extend to the aorta, producing, as in one of my cases, exten-
sive endarteritis with multiple acute aneurisms.
Associated Lesioxs. — The associated changes are those of the primary
disease, those due to embolism, and the changes in the myocardium. In the
endocarditis of septic processes there is the local lesion — an acute necrosis, a
suppurative wound, or puerperal disease. In many cases the lesions are those
of pneumonia, rheumatism, or other febrile processes.
The changes due to embolism constitute the most striking features, but it
is remarkable that in some instances, even with endocarditis of a markedly
ulcerative character, there may be no trace of embolic processes. The infarcts
may be few in number — only one or two, perhaps, in the spleen or kidney —
or they may exist in hundreds throughout the various parts of the body. They
may present the ordinary appearance of red or white infarcts of a suppurative
character. They are most common in the spleen and kidneys, though they may
be numerous in the brain, and in many cases are very abundant in the intes-
tines. In right-sided endocarditis there may be infarcts in the lungs. In
many of the cases there are innumerable miliar}^ abscesses. Acute suppurative
meningitis was met with in 5 of 23 of the Montreal cases, and in over 10 per
cent of the 209 cases analyzed in the literature. Acute suppurative parotitis
also may occur. And, lastly, as Eomberg has pointed out, the oft accompanying
myocarditis plays an important role. The valvular insufficiency in an acute
endocarditis is probably not due to the row of little vegetations, but to the
associated myocarditis, which interferes with the proper closure of the orifice.
Bacteriology. — Xo distinction in the micro-organisms found in the two
forms of endocarditis can be made. In both the pyogenic cocci — strepto-
cocci, staph3'lococci, pneumococci, and gonococci — are the most frequent bac-
teria met with. More rarely, especially in the simple vegetative endocarditis,
the bacilli of tuberculosis, typhoid fever, and anthrax have been encountered.
The bacillus coli communis has also been found, and Howard has described
a case of malignant endocarditis due to an attenuated form of the diphtheria
bacillus. Marshall in 61 cases found the pneumococci in 21, streptococci alone
DISEASES OF THE HEART. 789
or with other bacteria in 26, staphylococcus pyogenes aureus in 13. Combined
infections are not uncommon.
As a rule no organisms are found in the simple endocarditis in many
chronic diseases, as carcinoma, tuberculosis, nephritis, etc. They may have
been present and died out, or the lesions may be caused by the toxins.
Symptoms. — Neither the clinical course nor the physical signs of simple
ENDOCARDITIS are in any respect characteristic. The great majority of the
cases are latent and there is no indication whatever of cardiac mischief.
Experience has taught us that endocarditis is frequently found post mortem
in persons in whom it was not suspected during life. There are certain fea-
tures, however, by which its presence is indicated with a degree of probability.
The patient, as a rule, does not complain of any pain or cardiac distress. In
a case of acute rheumatism, for example, the symptoms to excite suspicion
would be increased rapidity of the heart's action, perhaps slight irregularity,
and an increase in the fever, without aggravation of the joint trouble. Eows of
tiny vegetations on the mitral or on the aortic segments seem a trifling matter
to excite fever, and it is difficult in the endocarditis of febrile processes to say
definitely in every instance that an increase in the fever depends upon this
complication ; but a study of the recurring endocarditis — which is of the warty
variety, consisting of minute beads on old sclerotic valves — shows that the
process may be associated, for days or weeks at a time, with slight fever ranging
from 100° to 102^°. Palpitation may be a marked feature and is a symptom
upon which certain authors lay great stress.
The diagnosis of the condition rests upon physical signs, which are
notoriously uncertain. The presence of a murmur at one or other of the car-
diac areas in a ease of fever is often taken as proof of the existence of endo-
carditis— a common mistake which has arisen from the fact that the hruit
de souffle or bellows murmur is common to it and to a number of other con-
ditions. At first there may be only a slight roughening of the first sound,
which may gradually increase to a distinct murmur. The apex systolic bruit
is probably more often the result of a myocarditis. It may not be present in
the endocarditis of such chronic maladies as tuberculosis and carcinoma, since
in them the muscle involvement is less common (Krehl). Reduplication and
accentuation of the pulmonic second sound are frequently present.
It is difficult to give a satisfactory clinical picture of malignant endo-
CAEDiTis because the modes of onset are so varied and the symptoms so diverse.
Arising in the course of some other disease, there may be simply an intensifica-
tion of the fever or a change in its character. In a majority of the cases there
are present certain general features, such as irregular pyrexia, sweating, delir-
ium, and gradual failure of strength.
Embolic processes may give special characters, such as delirium, coma or
paralysis from involvement of the brain or its membranes, pain in the side and
local peritonitis from infarction of the spleen, bloody urine from implication
of the kidneys, impaired vision from retinal haemorrhage and suppuration,
and even gangrene, in various parts from the distribution of the emboli.
Two special types of the disease have been recognized — the septic or pysemic
and the typhoid. In some the cardiac symptoms are most prominent, while in
others again the main symptoms may be those of an acute affection of the
cerebro-spinal system.
790 DISEASES OF THE CIRCULATORY SYSTEM.
The septic type is met witli usually in connection with an external wound,
the puerperal process, or an acute necrosis or gonorrhoea. There are rigors,
sweats, irregular fever, and all of the signs of septic infection. The heart
sj^mptoms may be completely masked by the general condition, and attention
called to them only on the occurrence of embolism. In many cases the features
are those of a severe septicemia, and the organisms may be isolated from the
blood.
The typhoid type is by far the most common and is characterized by a
less irregular temperature, early prostration, delirium, somnolence, and coma,
relaxed bowels, sweating, which may be of a most drenching character,
petechial and other rashes, and occasionally parotitis. The heart symptoms
may be comiDletely overlooked, and in some instances the most careful exam-
ination has failed to discover a murmur.
Under the cardiac groups as suggested by Bramwell, may be considered
those cases in which patients with chronic valve disease are attacked with
marked fever and evidence of recent endocarditis. Many such cases present
symptoms of the pygemic and t^^hoid character and run a most acute course.
In others there may be only slight fever or even after a period of high fever
recovery takes place.
In what may be termed the cerebral group of cases the clinical picture
may simulate a meningitis, either basilar or cerebro-spinal. There may be
acute delirium or, as in three of the Montreal cases, the patient may be brought
into the hospital unconscious. Heineman reports an instance, with autopsy,
in which the clinical picture was that of an acute cerebro-spinal meningitis.
Certain special symptoms may be mentioned. The fever is not always of
a remittent tA-pe. but may be high and continuous. Petechial rashes are very
common and render the similarity very strong to certain cases of typhoid and
cerebro-spinal fever. In one case the disease was thought to be hgemorrhagie
small-pox. Erythematous rashes are not uncommon. The sweating may be
most profuse, even exceeding that which occurs in phthisis and ague. Diar-
rhoea is not necessarily associated vdth embolic lesions in the intestines.
Jaimdice has been observed and cases are on record which were mistaken for
acute yellow atrophy.
The heart symptoms may be entirely latent and are not found unless a
careful search be made. Even on examination there may be no murmur
present. Instances are recorded by careful observers, in which the examination
of the heart has been negative. Cases with chronic valve disease usually pre-
sent no diflBculty in diagnosis.
The course of the disease is varied, depending largely upon the nature of
the primary trouble. Except in the disease grafted upon chronic valvulitis
the course is rarely extended beyond five of six weeks. The most rapidly fatal
case on record is described by Eberth, the duration of which was scarcely two
days. There is, however, a remarkable form characterized by an unusual
chronicity, to which the name may be given of cheoxic ixfective endo-
CAEDiTis. It is almost always engrafted on an old, sometimes an unrecog-
nized, valve lesion. At fii'st fever is the only symptom; in a few cases there
have been chills at onset or recurring chills may arouse the suspicion of
malaria. The patient may keep at work for months with a daily rise of
temperature, or perhaps an occasional sweat. The heart features may be
DISEASES OF THE HEART. 791
overlooked. The murmur of the old valve lesion may show no change, and
even with the most extensive disease of the mitral cusps the heart's action
may be very little disturbed. For months — six, eight, ten, even thirteen ! —
fever and progressive weakness may be the only symptoms. These are the
cases in which, with recurring chills, the diagnosis of malaria is made. With
involvement of the aortic segments the signs of a progressive lesion are more
common. Embolic features are not common, occurring only toward the close.
Post mortem there has been found in my cases a remarkable vegetative endo-
carditis, involving usually the mitral valves, sometimes with much encrusting
of the chordge tendine^, and large irregular firm vegetations quite different
to those of the ordinary ulcerative form of the disease. In some cases the
aortic and tricuspid segments are also involved, and the vegetations may extend
on to the walls of the heart.
Diagnosis. — In many cases the detection of the disease is very difficult;
in others, with marked embolic symptoms, it is easy. From simple endocarditis
it is readily distinguished, though confusion occasionally occurs in the tran-
sitional stage, when a simple is developing into a malignant form. The con-
stitional symptoms are of a graver type, the fever is higher, rigors are common,
and septic and typhoid symptoms occur. Perhaps a majority of the cases not
associated with puerperal processes or bone-disease are confounded with
typhoid fever. A differential diagnosis may even be impossible, particularly
when we consider that in typhoid fever infarctions and parotitis may occur.
The diarrhoea and abdominal tenderness may also be present, which with the
stupor and progressive asthenia make a picture not to be distinguished from
this disease. Points which may guide us are : The more abrupt onset in endo-
carditis, the absence of any regularity of the pyrexia in the early stage of the
disease, and the cardiac pain. Oppression and shortness of breath may be
early symptoms in malignant endocarditis. Eigors, too, are not uncommon.
There is a marked leucocytosis in infective endocarditis. Between pyaemia and
malignant endocarditis there are practically no differential features, for the
disease really constitutes an arterial pywmia (Wilks). In the acute cases
resembling malignant fevers, the diagnosis is usually made of typhus, typhoid,
cerebro-spinal fever, or even of hsemorrhagic small-pox. The intermittent
pyrexia, occurring for weeks or months, has led in some cases to the diagnosis
of malaria, but this disease could now be positively excluded by the blood
examination. Blood cultures may aid greatly in the diagnosis.
The cases usually terminate fatally. The instances of recovery are those
more subacute forms, the so-called recurring endocarditis developing on old
sclerotic valves in cases of chronic heart-disease.
Treatment. — We know no measures by which in rheumatism, chorea, or
the eruptive fevers the onset of endocarditis can be prevented. As it is
probable that many cases arise, particularly in children, in mild forms of
these diseases, it is well to guard the patients against taking cgld and insist
upon rest and quiet, and to bear in mind that of all complications an acute
endocarditis, though in its immediate effects harmless, is perhaps the most
serious. This statement is enforced by the observations of Sibson that on a
system of absolute rest the proportion of cases of rheumatism attacked by
endocarditis was less than of those who were not so treated. It is doubtful
whether the salicylates in rheumatism have an influence in reducing the lia-
792 DISEASES OF THE CIRCULATORY SYSTEM.
bility to endocarditis. Considering the extremely grave after-results of simple
endocarditis in children, the question arises whether it is possible to do any-
thing, to avert the onset of progressive sclerosis of the affected valve. Caton
recommends a systematic plan of treatment : ( 1 ) Prolonged rest in bed, three
months, to keep the heart quiet; (3) a series of small blisters over the heart;
and (3) tlie iodide of potassium in moderate doses for many months. If
there is much vascular excitement aconite may be given and an ice-bag placed
over the heart. The salicylates are strongly advised by some writers. The
treatment of malignant endocarditis is practically that of septicaemia — ^useless
and hopeless in a majority of the cases. Blood cultures should be taken as
soon as possible and a vaccine prepared. Horder and others have reported
good results. Personally I have not seen a successful case.
Chronic Endocaeditis.
Definition. — A sclerosis of the valves leading to shrinking, thickening, and
adhesion of the cusps, often with the deposition of lime salts, with shortening
and thickening of the chordse tendinese, leading to insufficiency and to narrow-
ing of the orifice. It may be primary, but is of tener secondary to acute endo-
carditis, particularly the rheumatic form.
Etiology. — As age advances the valves begin to lose their pliancy, show
slight sclerotic changes and foci of atheroma and calcification. Certain poi-
sons appear capable of initiating the change, such as alcohol, lead, syphilis,
and gout, though we are at present ignorant of the way in which they act.
The poisons of the specific fevers may initiate the change. A very important
factor, particularly in the case of the aortic valves, is the strain of prolonged
and heavy muscular exertion. In no other way can be explained the occur-
rence of sclerosis of these valves in young and middle-aged men whose occu-
pations necessitate the overuse of the muscles. In the aortic segments it may
be only the valvular part of a general arterio-sclerosis.
The frequency with which chronic endocarditis is met with may be gath-
ered from the following figures : In the statistics, amounting to from 12,000
to 14,000 autopsies, reported from Dresden, Wiirzburg, and Prague the per-
centage ranged from four to nine. The relative frequency of involvement of
the various valves is thus given in the collected statistics of Parrot : The mitral
orifice was involved in 631, the aortic in 380, the tricuspid in 46, and the pul-
monary in 11, This gives 57 instances in the right to 1,001 in the left heart.
Morbid Anatomy. — Vegetations in the form in which they occur in acute
endocarditis are not present. In the early stage, which we have frequent oppor-
tunities of seeing, the edge of the valve is a little thickened and perhaps pre-
sents a few small nodular prominences, which in some cases may represent the
healed vegetations of the acute process. In the aortic valves the tissue about
the corpora Arantii is first affected, producing a slight thickening with an
increase in the size of the nodules. The substance of the valve may lose its
translucency, and the only change noticeable be a grayish opacity and a slight
loss of its delicate tenuity. In the auriculo-ventricular valves these early
changes are seen just within the margin and here it is not uncommon to find
swelHngs of a grayish-red, somewhat infiltrated appearance, almost identical
with the similar structures on the intima of the aorta in arterio-sclerosis.
Even early there may be seen yellow or opaque-white subintimal fatty degen-
DISEASES OF THE HEART. 793
erated areas. As the sclerotic changes increase, the fibrous tissue contracts
and jaroduces thickening and deformity of the segment, the edges of which
become round, curled, and incapable of that delicate apposition necessary for
perfect closure. A sigmoid valve, for instance, may be narrowed one-fourth
or even one-third across its face, the most extreme grade of insufficiency being
induced without any special deformity and without any narrowing of the
arterial orifice. In the auriculo-ventricular segments a simple process of
thickening and curling of the edges of the valves, inducing a failure to close
without forming any obstruction to the normal course of the blood-flow, is less
common. Still, we meet with instances at the mitral orifice, particularly in
children, in which the edges of the valves are curled and thickened, so that
there is extreme insufficiency without any material narrowing of the orifice.
More frequently, as the disease advances, the chordae tendinese become thick-
ened, first at the valvular ends and then along their course. The edges of
the valves at their angles are gradually drawn together and there is a nar-
rowing of the orifice, leading in the aorta to more or less stenosis and in the
left auriculo-ventricular orifice — the two sites most frequently involved — to
constriction. Finally, in the sclerotic and necrotic tissues lime salts are depos-
ited and may even reach the deeper structures of the fibrous rings, so that the
entire valve becomes a dense calcareous mass with scarcely a remnant of nor-
mal tissue. The chordae tendinese may gradually become shortened, greatly
thickened, and in extreme cases the papillary muscles are implanted directly
upon the sclerotic and deformed valve. The apices of the papillary muscles
usually show marked fibroid change.
In all stages of the process the vegetations of simple endocarditis may
be present, and the severer, ulcerative forms are very apt to attack these
sclerotic valves.
Chronic mural endocarditis produces cicatricial-like patches of a grayish-
white appearance which are sometimes seen on the muscular trabeculge of
the ventricle or in the auricles. It often occurs in association with myo-
carditis.
The endocarditis of the. foetus is usually of the sclerotic form and in-
volves the valves of the right more frequently than those of the left side.
II. CHRONIC VALVULAR DISEASE.
1. General Introduction.
Effects of Valve Lesions. — The general influence on the work of the heart
may be briefly stated as follows : The sclerosis induces insufficiency or stenosis,
which may exist separately or in combination. The narrowing retards in a
measure the normal outflow and the insufficiency permits the blood current
to take an abnormal course. In both instances the effect is dilatation of a
chamber. The result in the former case is an increase in the difficulty which
the chamber has in expelling its contents through the narrow orifice; in the
other, the overfilling of a chamber by blood flowing into it from an improper
source, as, for instance, in mitral insufficiency, when the left auricle receives
blood both from the pulmonary veins and from the left ventricle.
The cardiac mechanism is fully prepared to meet ordinary grades of
52
794
DISEASES OF THE CIRCULATORY SYSTEM.
dilatation which constantly occur during sudden exertion. A man, for in-
stance, at the end of a hundred-yard race has his right cliambers greatly dilated
and his reserve cardiac power worked to its full capacity. The slow progress
of the sclerotic changes brings about a gradual, not an abrupt, insufficiency,
and the moderate dilatation which follows is at first overcome by the exercise
of the ordinary reserve strength of the heart muscle. Gradually a new factor
is introduced. The reserve power which is capable of meeting sudden emer-
gencies in such a remarkable manner is unable to cope long with a permanent
and perhaps increasing dilatation. More work has to be done and, in accord-
ance vrith definite physiological laws, more power is given by increase of the
muscles. The heart h^-pertrophies and the effect of the valve lesion becomes,
as we say, compensated. The equilibrium of the circulation is in this way
maintained.
The nature of the process with which we have to deal is graphically illus-
trated in the accompanying diagram, from ]\Iartius. The perpendicular lines
in the figures represent the power of work of the heart. While the muscle
J?eserve-force =
Accommodation- s
capacity
Reserve-force =
Accommodation-
capacity
•^b
Power of work
(body at rest)
lb.
K^ Power of work
f^ (body at rest)
Total power of heart
y less than amount needed
when the body is at rest.
Insufficiency of the heaiJi
I. Normal heart
Heart in valvular disease ir^
stage of compensation
Chart XXI.
m. Heart in uncompensated
valvular disease
in the healthy heart (Diagram I) has at its disposal the maximal force, a c,
it carries on its work under ordinary circumstances (when the body is at rest)
with the force a &. & c is the reserve force by means of which the heart
accommodates itself to greater exertion.
If now there be a gross valvular lesion, the force required to do the ordi-
nary work of the heart (at rest) becomes very much increased (Diagram II).
But in spite of this enormous call for force, insufficiency of the heart muscle
does not necessarily result, for the working force required is still within the
limits of the maximal power of the heart, fli &i being less than a^ c^. The
DISEASES OF THE HEART. 795
muscle accommodates itself to the new conditions by making its reserve force
mobile. If nothing further occurred, however, this condition could not be
permanently maintained, for there would be left over for emergencies only
the small reserve force, h-^y. Even when at rest the heart would be using con-
tinuously almost its entire maximal force. Any slight exertion requiring more
extra force than that represented by the small value h^y (say the effort required
on walking or on going upstairs) would bring the heart to the limit of its work-
ing power, and palpitation and dyspnoea would appear. Such a condition does
not last long. The working power of the heart gradually increases. More and
more exertion can be borne without causing dyspnoea, for the heart hyper-
trophies. Finally, a new, more or less permanent condition is attained, in that
the hypertrophied heart possesses the maximal force, a^ c^. Owing to the
increase in volume of the heart muscle, the total force of the heart is greater
absolutely than that of the normal heart by the amount y c^. It is, however,
relatively less efficient, for its reserve force is much less than that of the healthy
heart. Its capacity for accommodating itself to unusual calls upon it is accord-
ingly permanently diminished.
Turning now to the disturbances of compensation, it is to be distinctly
borne in mind that any heart, normal or diseased, can become insufficient
whenever a call upon it exceeds its maximal working capacity. The liability
to such disturbance will depend, above all, upon the accommodation limits of
the heart — the less the width of the latter, the easier will it be to go beyond the
heart's efficiency. A comparison of Diagrams I and II will immediately make
it clear that the heart in valvular disea se will much earlier become, insufficient
than the heart of a healthy individual. If the heart muscle is compelled to do
maximal or nearly maximal work for a long time, it becomes exhausted. It is
obvious that the heart in valvular disease, on account of its small amount of re-
serve force, has to do maximal or nearly maximal work far more frequently than
does the normal heart. The power of the heart may become decreased to the
amount necessary simply to carry on the work of the heart when the body is
at rest, or it may cease to be sufficient even for this. The reserve force gained
through the compensatory process may be entirely lost (Diagram III). If
the loss be only temporary, the exhausted heart muscle quickly recovering,
the condition is spoken of as a " disturbance of compensation." The term
" loss of compensation " is reserved for the condition in which the disturbance
is continuous.
The schema of Martins (Chart XXII) will enable the student to under-
stand the relation of the pathological phenomena to the normal cardiac cycle.
The contraction of the ventricle takes an appreciable period of time, seven-
hundred ths of a second {a-b) to overcome the strong arterial pressure which
keeps the aortic (and pulmonary) doors tightly shut. This closure-time is the
only brief period in the cycle in which both the auriculo-ventricular valves and
the semilunar valves are shut, the former as a result of the beginning of the
systole, the latter until the intra-ventricular has overcome the aortic pressure.
With this closure-time correspond the first sound and the heart beat. In the
second period of the ventricular systole the blood is driven into the arteries —
the expulsion-time (b-c) — and this corresponds with the beginning of the
aortic pulse. During this there may be seen at the apex in a forcibly beating
heart the "back stroke/' as Hope called it. Following the expulsion-time
796
DISEASES OF THE CIRCULATORY SYSTEM.
there is a brief period — waiting-time (c-d) — before the diastole begins. Clini-
cally the murmur of mitral insufficiency (A) coincides, at any rate in its
beginning, with the closure-time, the murmur of aortic stenosis with the
expulsion-time. The semilunar Talves close at the moment when the ventricles
begin to relax (d) and with this coincides the second sound. At the same
moment the auriculo-ventricular valves open. The murmur of aortic insuf-
Xitral
InsufficiexLcy
Aortic Stenosis
Ventricular Systole
Closure-Time
I Sound
aud
Impulse
Expulsion Time tc
''Back Stroke"
c
Aortic Insufficiency
II Sound
a
Closure of
the Auriculo-
ventricular
Valves
6
Opening of
the Semilunar
Valves
C d
Closure of the Semilunar
and Opening of the Auriculo-
ventricular Valves
Chart XXII. — Schematic Division of the Phases of the Heart's Action (Martius).
ficiency (C) is heard through the first part of the diastole, sometimes more,
while the murmur of mitral stenosis {D) corresponds with the latter part of
the diastole of the ventricles and with the systole of the auricles {D).
The incidence of valvular lesions may be gathered from the following
figures compiled by Gillespie from the records of the Eoyal Infirmary, Edin-
burgh: Of "2,368 cases with cardiac lesions, valvular disease occurred in 80.8
per cent; endocarditis and pericarditis in 5.3; myocardial lesions in 11.9 per
cent; 66.2 per cent of the cases were in males.
2. Aortic Ixcompetenct.
Incompetency of the aortic valves arises either from inability of the valve
segments to close an abnormally large orifice or more commonly from disease
of the segments themselves. This best-defined and most easily recognized of
valvular lesions was first carefully studied by Corrigan, whose name it some-
times bears.
Etiology and Morbid Anatomy. — It is more frequent in males than in
females, affecting chiefly able-bodied, vigorous men at the middle period of
life. The ratio which it bears to other valve diseases has been variously
given as from 30 to 50 per cent.
DISEASES OF THE HEART. 797
There are five groups of cases: I. Those due to congenital malformation,
particularly fusion of two of the cusps — most commonly those behind which
the coronary arteries are given off. It is probable that an aortic orifice
may be competent with this bicuspid state of the valves, but a great dan-
ger is the liability of these malformed segments to sclerotic endocarditis.
Of 17 cases which I have reported all presented sclerotic changes, and the
majority of them had, during life, the clinical features of chronic heart-
disease.
II. The endocarditic group. Endocarditis may produce an acute insuffi-
ciency by ulceration and destruction of the valves; in one case the aortic
valves were completely eroded away. The valvulitis of rheumatism and of
the fevers, while more rarely aortic, is common enough in children, and
the insufficiency is caused by nodular excrescences at the margins or in the
valves, which may ultimately become calcified; more often it induces a
slow sclerosis of the valves with adhesions, causing also some degree of
narrowing.
III. The arteriosclerotic group. By far the most frequent cause of in-
sufficiency is a slow, progressive sclerosis of the segments, resulting in a
curling of the edges, which lessens the working surface of the valve. Most
frequent in strong, able-bodied men, there are three main factors in its pro-
duction : Firsty strain — not a sudden, forcible strain, but a persistent increase
of the normal tension to which the segments are subject during the diastole
of the ventricle. Of circumstances increasing this tension, repeated and exces-
sive use of the muscles is perhaps the most important. So often is this form
of heart-disease found in persons devoted to athletics that it is sometimes
called the " athlete's heart.'' Secondly, alcohol, the action of which is prob-
ably direct as a poison to the vessel wall and not, as we have supposed here-
tofore, in keeping up a high blood pressure. Thirdly, syphilis, which may
be only one of several elements in inducing early arterial change, an added
factor to the wear and tear of the tubing.
There is a small group, usually in young_ men, in which syphilis causes a
localized arterio-sclerosis at the root of the aorta, either involving the valves
themselves or more frequently causing dilatation of the aortic ring with rela-
tive insufficiency. The endarteritis may be singularly localized, even annular,
sometimes patchy. It may be difficult or impossible from the lesion itself to
determine the syphilitic nature; the youth of the patient, the peculiar local-
ization, the history of syphilis, and the existence of syphilitic lesions elsewhere,
may render the diagnosis tolerably certain. I am in the habit of enforcing
upon my students the etiological lesson of this type of aortic insufficiency
by a reference to Bacchus and Vulcan, at whose shrines a majority of patients
with aortic insufficiency have worshipped, and not a few at those of Mars
and Venus.
The condition of the valves is such as has already been described in
chronic endocarditis. It may be noted, however, how slight a grade of curl-
ing may produce serious incompetency. Associated with the valve disease is,
in a majority of cases, a more or less advanced arterio-sclerosis of the arch of
the aorta, one serious effect of which may be a narrowing of the orifices of
the coronary arteries. The sclerotic changes are often combined with athe-
roma, either in a fatty or calcareous stage. This may exist at the attached
798 DISEASES OF THE CIRCULATORY SYSTEM.
margin of the valves without inducing insuliiciency. In other instances insuf-
ficiency may result from a calcified spike projecting from the aortic attach-
ment into the body of the valve, and so preventing its proper closure. Some
writers (Peter) have laid great stress upon the extension of the endarteritis
to the valve, and would separate the instances of this kind from those of
simple valvular endocarditis. Anatomically one can usually recognize the
arterio-sclerotic variety by the smooth surface, the rounded edges, and the
absence of excrescences.
IV. Insufficiency may be induced by rupture of a segment — a very rare
event in healthy valves, but not uncommon in disease, either from excessive
effort during heavy lifting or from the ordinary endarterial strain on a valve
eroded and weakened by ulcerative endocarditis.
V. Relative insufficiency^ due to dilatation of the aortic ring and adjacent
arch, is not very infrequent. It occurs in extensive arterial sclerosis of the
ascending portion of the arch with great dilatation just above the valves.
The valve segments are usually involved with the arterial coats, but the changes
in them may be very slight. In aneurism just above the aortic ring, relative
insufficiency of the valve may be present.
It would appear from the careful measurements of Beneke that the aortic
orifice, which at birth is 20 mm., increases gradually with the growth of the
heart until at one-and-twenty it is about 60 mm. At this it remains until the
age of forty, beyond which date there is a gradual increase in the size up
to the age of eighty, when it may reach from 68 to 70 mm. There is thus
at the very period of life in which sclerosis of the valve is most common a
physiological tendency toward the production of a state of relative insuf-
ficiency.
The insufficiency may be combined with various grades of narrowing, par-
ticularly in the endocarditic group. In a majority of the cases of the arterio-
sclerotic form there is no stenosis. On the other hand, aortic stenosis almost
without exception is associated with some grade, however slight, of regur-
gitation.
Effects. — The direct effect of aortic insufficiency is the regurgitation of
blood from the artery into the ventricle, causing an overdistention of the
cavity and a reduction of the blood column; that is, a relative anaemia in the
arterial tree. The amount returning varies with the size of the opening. The
double blood-flow into the left ventricle causes dilatation of the chamber, and
finally hypertrophy, the grade depending upon the lesion. In this way the
valve defect is compensated, and as with each ventricular systole a larger
amount of blood is propelled into the arterial system, the regurgitation of a
certain amount during diastole does not, for a time at least, seriously impair
the nutrition of the peripheral parts. For a time at least there is little or
no resistance offered to the blood-flow from the auricle — the ventricle accom-
modates itself readily to the extra amount, and there is no disturbance in the
lesser circulation. In acute cases, on the other hand, vdth rapid destruction
of the segments, there may be the most intense dyspncea and even profuse
haemoptysis. In this lesion dilatation and hypertrophy reach their most ex-
treme limit. The heaviest hearts on record are described in connection with
this affection. The so-called bovine heart, cor iovinum, may weigh 35 or 40
ounces, or even, as in a case of DuUes's, 48 ounces. The dilatation is usually
DISEASES OF THE HEART. 799
extreme and is in marked contrast to the condition of the chamber in cases of
pure aortic stenosis. The papillary muscles may be greatly flattened. The
mitral valves are usually not seriously affected, though the edges may present
elight sclerosis, and there is often relative incompetency, owing to distention
of the mitral ring. Dilatation and hypertrophy of the left auricle are com-
mon, and secondary enlargement of the right heart occurs in all cases of
long standing. In the arterio-sclerotic group there is an ever present pos-
sibility of narrowing of the orifices of the coronary arteries or an extension of
the sclerosis to their branches, leading to fibroid myocarditis. In the endo-
carditis cases, particularly those following rheumatism, the intima is perfectly
smooth, and the arch with its main branches not dilated. A normal aorta may
be found post mortem when during life there have been the most character-
istic signs of enlargement of the arch and of dilatation of the innominate and
right carotid. The so-called dynamic dilatation of the arch is best seen in
these cases. A young girl, whose case has been reported as one of aneurism,
had forcible pulsation and a tumor which could be grasped above the sternum.
— post mortem the innominate artery did not admit the little finger and the
arch was not dilated !
Although the coronary arteries, as shown by Martin and Sedgwick, are
filled during the ventricular systole, the circulation in them must be embar-
rassed in aortic incompetency. They must miss the effect of the blood-pressure
in the sinuses of Valsalva during the elastic recoil of the arteries, which surely
aids in keeping the coronary vessels full. The arteries of the body usually
present more or less sclerosis consequent upon the strain which they undergo
during the forcible ventricular systole.
Symptoms. — The condition is often discovered accidentally in persons who
have not presented any features of cardiac disease.
Headache, dizziness, flashes of light, and a feeling of faintness on rising
quickl}^ are among the earliest symptoms. Palpitation and cardiac distress on
slight exertion are common. Long before any signs of failing compensation
pain may become a marked and troublesome feature. It is extremely variable
in its manifestations. It may be of a dull, aching character confined to the
prsecordia. More frequently, however, it is sharp and radiating, and is trans-
mitted up the neck and down the arms, particularly the left. Attacks of true
angina pectoris are more frequent in this than in any other valvular disease.
Anaemia is also common, much more so than in aortic stenosis or in mitral
affections.
As compensation fails more serious sjmiptoms are shortness of breath
and oedema of the feet. The attacks of dyspnoea are liable to come on at
night, and the patient has to sleep with his head high or even in a chair.
Cyanosis is rare. It is most commonly due to complicating valve disease, or
it is stated that it may result from bulging of the septum ventriculorum and
encroachment upon the right ventricle. Of respiratory symptoms cough is com-
mon, due to the congestion of the lungs or oedema. Haemoptysis is less fre-
quent than in mitral disease. I have reported a case in which it was profuse
and believed to be due to tuberculosis of the lungs, inasmuch as the patient was
admitted in a state of emaciation and profound exhaustion. General dropsy
is not common, but cedema of the feet may occur early and is sometimes due
to the anemia, sometimes to the venous stasis, at times to both. Unless there
800 DISEASES OF THE CIRCULATORY SYSTEM.
is coexisting disease of the mitral valve, it is rare in aortic incompetency for
the patient to die with general anasarca. Sudden death is frequent; more
so in this than in other valvular diseases. As compensation fails the patient
takes to bed and slight irregular fever, associated usually with a recurring
endocarditis, is not uncommon toward the close. Embolic symptoms are not
infrequent — pain in the splenic region with enlargement of the organ, hsema-
turia, and in some cases paralysis. . Distressing dreams and disturbed sleep
are more common in this than in other forms of valvular disease.
Mental s}Tnptoms are often seen with this lesion; toward the close there
may be delirium, hallucinations, and morbid impulses. It is important to bear
this in mind, for patients occasionally display suicidal tendencies. I have
twice had patients throw themselves from a window of the ward.
Physical Sigxs. — Inspection shows a wide and forcible area of cardiac
impulse with the apex beat in the sixth or seventh interspace, and perhaps
as far out as the anterior axillary line. In young subjects the prtecordia
may bulge. There may be slight visible pulsation in the second right inter-
space, or, in some acute cases of insufficiency or ulcerative endocarditis, a
couple of inches from the sternal margin. In very slight insufficiency there
may be little or no enlargement to be determined clinically. On palpation a
thrill, diastolic in time, is occasionally felt, but is not common. The impulse
is usually strong and heaving, unless in conditions of extreme dilatation, when
it is wavy and indefinite. Occasionally two or three interspaces between the
nipple line and sternum will be depressed with the systole as the result of
atmospheric pressure. Percussion shows a greater increase in the area of
heart dulness than is found in any other valvular lesion. It extends chiefly
downward and to the left.
Auscultation. — A murmur is heard during the diastole of the ventricles
at the base of the heart and propagated down the sternum. It may be feeble
or inaudible at the aortic cartilage, and is usually heard best at midsternum
opposite the third costal cartilage or along the left border of the sternum
as low as the ensiform cartilage. It is usually soft, blowing in quality, and
is prolonged, or " long drawn," as the phrase is. It is produced by the reflux
of blood into the ventricle. In some cases it is loudly transmitted to the
axilla at the level of the fourth interspace, not by way of the apex. The
second sound may be well heard or it may be replaced by the murmur, or
with a dilated and calcified arch the second sound may have a ringing metallic
or booming quality, and the diastolic murmur is well heard, or even loudest,
over the manubrium.
The first sound may be clear at the base; more commonly there is a soft,
short, systolic murmur. In the arterio-sclerotic group the systolic bruit is, as
a rule, short and soft, while in the endocarditic group, in which the valve seg-
ments are united and often covered with calcified vegetations and excrescences,
the sj^stolic murmur is rough and may be accompanied by a thrill.
At the apex, or toward it, the diastolic murmur may be faintly heard propa-
gated from the base. With full compensation the first sound is usually clear
at the apex ; with dilatation there is a loud systolic murmur of relative mitral
insufficiency, which may disappear under observation as the dilatation lessens.
A second murmur at the apex, probably produced at the mitral orifice,
is not uncommon. Attention was called to this bv the late Austin Flint,
DISEASES OF THE HEART. 801
and the murmur usually goes by his name. It is of a rumbling, echoing
character, occurring in the middle or latter part of diastole, usually pre-
systolic in time, and limited to the apex region. It is similar to, though
less intense than, the louder presystolic murmurs of mitral stenosis, and is
often associated with a palpable thrill. It is probably caused by the imping-
ing of the regurgitant current from the aortic orifice on the large, anterior
flap of the mitral valve, so as to cause interference with the entrance of blood
at the time of auricular contraction. The condition is thus essentially the
same as in a moderate mitral stenosis. This late diastolic echoing or rum-
bling murmur is present in about half of the cases, of uncomplicated aortic
insufficiency (Thayer). It is very variable, disappearing and reappearing
again without apparent cause. The sharp, valvular first sound and abrupt
systolic shock, so common in true mitral stenosis, are rarely present, while the
pulse is characteristic of uncomplicated aortic insufficiency.
Arteries. — The examination of the arteries in aortic insufficiency is of great
value. Visible pulsation is more commonly seen in the peripheral vessels in
this than in any other condition. The carotids may be seen to throb forcibly,
the temporals to dilate, and the brachials and radials to expand with each
heart-beat. With the ophthalmoscope the retinal arteries are seen to pulsate.
JSTot only is the pulsation evident, but the characteristic jerking quality is
apparent. In the throat the throbbing carotids may lead to the diagnosis of
aneurism. In many cases the pulsation can be seen in the suprasternal notch,
and prominent, forcibly throbbing vessels beneath the right sterno-mastoid
muscle. The abdominal aorta may lift the epigastrium with each, systole. To
be mentioned with this is the capillary pulse, met very often in the aortic
insufficiency, and best seen in the finger-nails or by drawing a line upon the
forehead, when the margin of hypergemia on either side alternately blushes and
pales. In extreme grades the face or the hand may blush visibly at each
systole. It is met with also in profound ansemia, occasionally in neurasthenia,
and in health in conditions of great relaxation of the peripheral arteries. Pul-
sation may also be present in the peripheral veins. On palpation the character-
istic water-hammer or Corrigan pulse is felt. In the majority of instances the
pulse wave strikes the finger forcibly with a quick jerking impulse, and imme-
diately recedes or collapses. The characters of this are sometimes best appre-
ciated by grasping the arm above the wrist and holding it up. Moreover, the
pulse of aortic regurgitation js usually retarded or delayed — i. e., there is an
appreciable interval between the beat of the heart and the pulsation in the
radial artery, which varies according to the extent of the incompetence. Occa-
sionally in the carotid artery the second sound is distinctly audible when absent
at the aortic cartilage. Indeed, according to Broadbent, it is at the carotid
that we must listen for the second aortic sound, for when heard it indicates that
the regurgitation is small in amount, and is consequently a very favorable
prognostic element. In the larger arteries a systolic thud or shock may be
heard and sometimes a double murmur, as pointed out by Duroziez. The sys-
tolic pressure is high and the diastolic much decreased. The sphygmo-
graphic tracing is very characteristic. The high ascent, the sharp top, the
quick drop in which the dicrotic notch and wave are very slightly marked.
Aortic insufficiency may for years be fully compensated. Persons do not
necessarily suffer any inconvenience, and the condition is often found accident-
S02 DISEASES OF THE CIRCULATORY SYSTEM.
ally. So long as the hypertrophy just equalizes the valvular defect there may
be no symptoms and the individual may even take moderately heavy exercise
without experiencing sensations of distress about the heart. The cases which
last the longest are those in which the insufficiency follows endocarditis and is
not a part of a general arterio-sclerosis. The age of the patient, too, at the
time of onset, is a most important consideration, as in youth the lesion is
not often from sclerosis, and the coronary arteries are unaffected. Coexistent
lesions of the mitral valves tend early to disturb the compensation. Pure
aortic insufficiency is consistent with years of average health and with a
tolerably active life.
With the onset of myocardial changes, with increasing degeneration of
the arteries, particularly with a progressive sclerosis of the arch and involve-
ment of the orifices of the coronary arteries, the compensation becomes dis-
turbed. In advanced cases the changes about the aortic ring may be asso-
ciated with alterations in the cardiac nerves and ganglia, and so introduce an
important factor.
3. Aortic Stenosis.
Narrowing or stricture of the aortic orifice is not nearly so common as
insuflficiency. The two conditions, as already stated, may occur together, how-
ever, and probably in almost every case of stenosis there is some leakage.
Etiology and Morbid Anatomy. — In the milder grades there is adhesion
between the segments, which are so stiffened that during systole they can not
be pressed back against the aortic wall. The process of cohesion between the
segments may go on without great thickening, and produce a condition in
which the orifice is guarded by a comparatively thin membrane, on the aortic
face of which may be seen the primitive raphes separating the sinuses of
Valsalva. In some instances this membrane is so thin and presents so few
traces of atheromatous or sclerotic changes that the condition looks as if it
had originated during foetal life. More commonly the valve segments are
thickened and rigid, and have a cartilaginous hardness. In advanced cases
they may be represented by stiff, calcified masses obstructing the orifice,
through which a circular or slit-like passage can be seen. The older the
patient the more likely it is that the valves will be rigid and calcified.
We may speak of a relative stenosis of the aortic orifice when with normal
valves and ring the aorta immediately beyond is greatly dilated. A stenosis
due to involvement of the aortic ring in sclerotic and calcareous changes with-
out lesion of the valves is referred to by some authors. I have never met with
an instance of this kind. A subvalvular stenosis, the result of endocarditis
in the mitro-sigmoidean sinus, usually occurs as the result of foetal endocar-
ditis. In comparison with aortic insufficiency, stenosis is a rare disease. It
is usually met with at a more advanced period of life than insufficiency, and
the most typical cases of it are found associated with extensive calcareous
changes in the arterial system in old men.
Owing to the impeded blood-fiow the ventricle has to work against an
increased resistance and its walls become hypertrophied, usually at first witli
little or no dilatation. We see in this condition the most typical instances of
what is called concentric hypertrophy, in which, without much, if any, en-
largement of the cavity, the walls are greatly thickened, in contradistinction
DISEASES OF THE HEART. 803
to the so-called eccentric hypertrophy, in which, with the increase in the thick-
ness of the walls, the chamber itself is greatly dilated. The systole is pro-
longed, even as much as twenty-five per cent. There may be no changes in
the other cardiac cavities if compensation is well maintained; but with its
failure come dilatation, impeded auricular discharge, pulmonary congestion,
and increased work for the right heart. The arterial changes are, as a rule,
not so marked as in aortic insufficiency, for the walls have not to withstand
the impulse of a greatly increased blood-wave with each systole. On the con-
trary, the amount of blood propelled through the narrow orifice may be smaller
than normal, though when compensation is fully established the pulse-wave
may be of medium volume.
Symptoms. — Physical Signs. — Inspection may fail to reveal any area
of cardiac impulse. Particularly is this the case in old men with rigid chest
walls and large emphysematous lungs. Under these circumstances there may
be a high grade of hypertrophy without any visible impulse. Even when the
apex beat is visible, it may be, as Traube pointed out, feeble and indefinite.
In many cases the apex is seen displaced downward and outward, and the
impulse looks strong and forcible.
Palpation reveals in many cases a thrill at the base of the heart of maxi-
mum force in the aortic region. With no other condition do we meet with
thrills of greater intensity. The apex beat may not be palpable under the
conditions above mentioned, or there may be a slow, heaving, forcible impulse.
Percussion never gives the same wide area of dulness as in aortic insuf-
ficiency. The extent of it depends largely on the state of the lungs, whether
emphysematous or not.
Auscultation. — A rough systolic murmur, of maximum intensity at the
aortic cartilage, and propagated into the great vessels, is the most constant
physical sign in aortic stenosis. One of the last lessons learned by the student
of physical diagnosis is to recognize that the systolic murmur at the aortic area
does not necessarily mean obstruction at the orifice. Eoughening of the valves,
or of the intima of the aorta, and haemic states are much more frequent causes.
In aortic stenosis the murmur often has a much harsher quality, is louder,
and is more frequently musical than in the conditions just mentioned. When
compensation fails and the ventricle is dilated and feeble, the murmur may be
soft and distant. The second sound is rarely heard at the aortic cartilage,
owing to the thickening and stiffness of the valve. A diastolic murmur is not
uncommon, but in many cases it can not be heard. Occasionally, as noted by
W. H. Dickinson, there is a musical murmur of greatest intensity in the region
of the apex, due probably to a slight regurgitation at high pressure through
the mitral valves. The pulse in pure aortic stenosis is small, usually of good
tension, well sustained, regular, and perhaps slower than normal.
The condition may be latent for an indefinite period, as long as the
hypertrophy is maintained. Early symptoms are those due to defective blood-
supply to the brain, dizziness, and fainting. Palpitation, pain about the
heart, and anginal symptoms are not so marked as in insufficiency. With
degeneration of the heart-muscle and dilatation relative insufficiency of the
mitral valve is established, and the patient may present all the features of
engorgement in the lesser and systemic circulations, with dyspnoea, cough,
rusty expectoration, and the signs of anasarca in the lower part of the body.
804 DISEASES OF THE CIRCULATORY SYSTEM.
Many of the cases in old people, without presenting any dropsy, have symp-
toms pointing rather to general arterial disease. Cheyne- Stokes breathing is
not uncommon with or without signs of uraemia.
Diagnosis. — With an extremely rough or musical murmur of maximum
intensity at the aortic region and signs of hypertrophy of the left ventricle, a
thrill, and especially a hard, slow pulse of moderate volume and fairly good
tension, which in a sphygmographic tracing gives a curve of slow rise, a
broad, well -sustained summit and slow decline, a diagnosis of aortic stenosis
can be made with some degree of certainty, particularly if the subject is an
old man. Mistakes are common, however, and a roughened or calcified valve
segment, or, in some instances, a very roughened and prominent calcified
plate in the aorta, and hypertrophy associated with renal disease, may produce
similar symptoms. Seldom is there difficulty in distinguishing the murmur
due to aneemia, since it is rarely so intense and is not associated with thrill
or with marked hypertrophy of the left ventricle. In aortic insufficiency a
systolic murmur is usually present, but has neither the intensity nor the
musical quality, nor is it accompanied with a thrill. With roughening and
dilatation of the ascending aorta the murmur may be very harsh or musical;
but the existence of a second sound, accentuated and ringing in quality, is
usually sufficient to differentiate this condition.
4. Mitral Incompetency.
Etiology. — Insufficiency of the mitral valve ensues: (a) From changes in
the segments whereby they are contracted and shortened, usually combined
with changes in the chordae tendineae, or with more or less narrowing of the
orifice. (&) As a result of changes in the muscular walls of the ventricle,
either dilatation, so that the valve segments fail to close an enlarged orifice,
or changes in the muscular substance, so that the segments are imperfectly
coapted during the systole — muscular incompetency. The common lesions
producing insufficiency result from endocarditis, which causes a gradual thick-
ening at the edges of the valves, contraction of the chordae tendincEe, and
union of the edges of the segments, so that in a majority of the instances there
is not only insufficiency, but some grade of narrowing as well. Except in
children, we rarely see the mitral leaflets curled and puckered without narrow-
ing of the orifice. Calcareous plates at the base of the valve may prevent
perfect closure of one of the segments. In long-standing cases the entire
mitral structures are converted into a firm calcareous ring. From this val-
vular insufficiency the other condition of muscular incompetency must be care-
fully distinguished. It is met with in all conditions of extreme dilatation of
the left ventricle, and also in weakening of the muscles in prolonged fevers
and in ansemia.
Morbid Anatomy. — The effects of incompetency of the mitral segment
upon the heart and circulation are as follows : (a) The imperfect closure allows
a certain amount of blood to regurgitate from the ventricle into the auricle,
so that at the end of auricular diastole this chamber contains not only the
blood which it has received from the lungs, but also that which has regur-
gitated from the left ventricle. This necessitates dilatation, and, as increased
work is thrown upon it in expelling the augmented contents, hypertrophy
as well.
DISEASES OF THE HEART. 805
(h) With each systole of the left auricle a larger volume of blood is forced
into the left ventricle, which also dilates and subsequently becomes hyper-
trophied.
(c) During the diastole of the left auricle, as blood is regurgitated into
it from the left ventricle, the pulmonary veins are less readily emptied. In
consequence the right ventricle expels its contents less freely, and in turn
becomes dilated and hypertrophied.
(^Z) Finally, the right auricle also is involved, its chamber is enlarged, and
its walls are increased in thickness.
(e) The effect upon the pulmonary vessels is to produce dilatation both
of the arteries and veins — often in long-standing cases, atheromatous changes ;
the capillaries are distended, and ultimately the condition of brown induration
is produced. Perfect compensation may be effected, chiefly through the hyper-
trophy of both ventricles, and the effect upon the peripheral circulation may
not be manifested for years, as a normal volume of blood is discharged from
the left heart at each systole. The time comes, however, when, owing either
to increase in the grade of the incompetency or to failure of the compensation,
the left ventricle is unable to send out its normal volume into the aorta.
Then there is overfilling of the left auricle, engorgement in the lesser cir-
culation, embarrassed action of the right heart, and congestion in the sys-
temic veins. For years this somewhat congested condition may be limited to
the lesser circulation, but finally the right auricle becomes dilated, the tri-
cuspid valves incompetent, and the systemic veins are engorged. This grad-
ually leads to the condition of cyanotic induration in the viscera and, when
extreme, to dropsical effusion.
Muscular incompetency, due to impaired nutrition of the mitral and papil-
lary muscles, is rarely followed by such perfect compensation. There may be
in acute destruction of the aortic segments an acute dilatation of the left
ventricle with relative incompetency of the mitral segments, great dilatation
of the left auricle, and intense engorgement of the lungs, under which circum-
stances profuse haemorrhage may result. In these cases there is little chance
for the establishment of compensation. In cases of hypertrophy and dilatation
of the heart, without valvular lesions, but associated with heavy work and
alcohol, the insufficiency of the mitral valve may be extreme and lead to great
pulmonary congestion, engorgement of the systemic veins, and a condition
of cardiac dropsy, which can not be distinguished by any feature from that
of mitral incompetency due to lesion of the valve itself. In chronic Bright's
disease the hypertrophy of the left ventricle may gradually fail, leading, in the
later stages, to relative insufficiency of the mitral valve, and the production
of a condition of pulmonary and systemic congestion, similar to that induced
by the most extreme grade of lesion of the valve itself. Adherent pericardium,
especially in children, may lead to like results.
Symptoms. — During the development of the lesion, unless the incom-
petency comes on acutely in consequence of rupture of the valve segment or of
ulceration, the compensatory changes go hand in hand with the defect, and
there are no subjective symptoms. So, also, in the stage of perfect compen-
sation, there may be the most extreme grade of mitral insufficiency with ejior-
mous hypertrophy of the heart, yet the patient may not be aware of the exist-
ence of heart trouble, and may suffer no inconvenience except perhaps a little
806 DISEASES OF THE CIRCULATORY SYSTEM.
shortness of breath on exertion or on going upstairs. It is only when from any
cause the compensation has not been perfectly effected, or, having been so,
is broken abruptly or gradually, that the patients begin to be troubled. The
symptoms may be divided into two groups :
(a) The minor manifestations while compensation is still good. Pa-
tients with extreme incompetency often have a congested appearance of
the face, the lips and ears have a bluish tint, and the venules on the cheeks
may be enlarged — signs in many cases very suggestive. In long-standing cases,
particularly in children, the fingers may be clubbed, and there is shortness
of breath on exertion. This is one of the most constant features in mitral
insufficiency, and may exist for years, even when the compensation is perfect.
Owing to the somewhat congested condition of the lungs these patients have
a tendency to attacks of bronchitis or hemoptysis. There may also be palpi-
tation of the heart. As a rule, however, in well-balanced lesions in adults,
this period of full compensation or latent stage is not associated with symp-
toms which call the attention to an affection of the heart, and with care the
patient may reach old age in comparative comfort without being compelled
to curtail seriously his pleasures or his work.
(h) Sooner or later comes a period of disturbed or broken compensation,
in which the most intense symptoms are those of venous engorgement. There
are palpitation, weak, irregular action of the heart, and signs of dilatation.
Dyspnoea is an especial feature, and there may be cough. A distressing symp-
tom is the cardiac " sleep-start," in which, just as the patient falls asleep, he
wakes gasping and feeling as if the heart were stopping. There is usually a
slight cyanosis, and even a jaundiced tint to the skin. The most marked
symptoms, however, are those of venous stasis. The overfilling of the pul-
monary vessels accounts in part for the dyspnoea. There is cough, often with
bloody or watery expectoration, and the alveolar epithelium containing brown
pigment-grains is abundant. Dropsical effusion usually sets in, beginning in
the feet and extending to the body and the serous sacs. Right-sided hydro-
thorax may recur and require repeated tapping. The urine is usually scanty
and albuminous, and contains tube-casts and sometimes blood-corpuscles. With
judicious treatment the compensation may be restored and all the serious symp-
toms may pass away. Patients usually have recurring attacks of this kind,
and die of a general dropsy; or there is progressive dilatation of the heart,
and death from asystole. Sudden death in these cases is rare. Some cases of
mitral disease — stenosis and insufficiency — ^reach what may be called the hepatic
stage, when all the symptoms are due to the secondary changes in the liver.
Physical Signs. — Inspection. — In children the prsecordia may bulge and
there may be a large area of visible pulsation. The apex beat is to the left
of the nipple, in some cases in the sixth interspace, in the anterior axillary
line. A localized right ventricle impulse may sometimes be seen below the
right costal border in the parsternal line. There may be a wavy impulse in
the cervical veins which are often full, particularly when the patient is
recumbent.
Palpation. — A thrill is rare; when present it is felt at the apex, often in
a limited area. The force of the impulse may depend largely upon the stage
in which the case is examined. In full compensation it is forcible and heav-
ing ; when the compensation is disturbed, usually wavy and feeble.
DISEASES OF THE HEART. 807
Permission. — The dulness is increased, particularly in a lateral direction.
There is no disease of the valves which produces, in long-standing cases, a
more extensive transverse area of heart dulness. It does not extend so much
upward along the left margin of the sternum as beyond the right margin and
to the left of the nipple line.
Auscultation. — At the apex there is a systolic murmur which wholly or
partly obliterates the first sound. It is loudest here, and has a blowing, some-
times musical character, particularly toward the latter part. The murmur is
transmitted to the axilla and may be heard at the back, in some instances
over the entire chest. There are cases in which, as pointed out by Naunj^n,
the murmur is heard best along the left border of the sternum. Usually in
diastole at the apex the loudly transmitted second sound may be heard. Occa-
sionally there is also a soft, sometimes a rough or rumbling presystolic mur-
mur. As a rule, in cases of extreme mitral insufficiency from valvular lesion
with great hypertrophy of both ventricles, there is heard only a loud blowing
murmur during systole. A murmur of mitral insufficiency may vary a great
deal according to the position of the patient. It may be present in the recum-
bent and absent in the erect posture. In cases of dilatation, particularly when
dropsy is present, there may be heard at the ensiform cartilage and in the
lower sternal region a soft systolic murmur due to tricuspid regurgitation. An
important sign on auscultation is the accentuated pulmonary second sound.
This is heard to the left of the sternum in the second interspace, or over the
third left costal cartilage.
The pulse in mitral insufficiency, during the period of full compensation,
may be full and regular, often of low tension. Usually with the first onset
of the symptoms the pulse becomes irregular, a feature which then dominates
the case throughout. There may be no two beats of equal force or volume.
Often after the disappearance of the symptoms of failure of compensation the
irregularity of the pulse persists.
The three important physical signs then of mitral regurgitation are: (a)
Systolic murmur of maximum intensity at the apex, which is propagated to
the axilla and heard at the angle of the scapula; (&) accentuation of the pul-
monary second sound; (c) evidence of enlargement of the heart, particu-
larly the increase in the transverse diameter, due to hypertrophy of both right
and left ventricles.
Diagnosis. — There is rarely any difficulty in the diagnosis of mitral insuf-
ficiency. The physical signs just referred to are quite characteristic and
distinctive. Two points are to be borne in mind. First, a murmur, systolic
in character, and of maximum intensity at the apex, and propagated even to
the axilla, does not necessarily indicate incompetency of the mitral valve.
There is heard in this region a large group of what are termed accidental
murmurs, the precise nature of which is still doubtful. They are probably
formed, however, in the ventricle, and are not associated with hypertrophy,
or accentuation of pulmonary second sound.
Second, it is not always possible to say whether the insufficiency is due
to lesion of the valve segment or to dilatation of the mitral ring and rela-
tive incompetency. Here neither the character of the murmur, the propa-
gation, the accentuation of the pulmonary second sound, nor the hypertrophy
assists in the differentiation. The history is sometimes of greater value in this
808 DISEASES OF THE CIRCULATORY SYSTEM.
matter than the physical examination. Tlie cases most likely to lead to error
are those of the so-called idiopathic dilatation and h3^pertrophy of the heart
(in which the systolic murmur may be of the greatest intensity), and the
instances of arterio-sclerosis with dilated heart. Balfour and others, however,
maintain that organic disease of the mitral leaflets sufficient to produce incom-
petency is always accompanied with a certain degree of narrowing of the ori-
fice, so that the only unequivocal proof of the actual disease of the mitral valve
is the presence of a presystolic murmur.
5. Mitral Stenosis.
Etiology. — Narrowing of the mitral orifice is usually the result of valvular
endocarditis occurring in the earlier years of life ; very rarely it is congenital.
It is very much more common in women than in men — in 63 of 80 cases noted
by Duckworth, while in 4,791 autopsies at Guy's Hospital during ten years
there were 196 cases, of which 107 were females and 89 males (Samways).
This is not easy to explain, but there are at least two factors to be considered.
Eheumatism prevails more in girls than in boys and, as is well known, endo-
carditis of the mitral valve is more common in rheumatism. Chorea, also, as
suggested by Barlow, has an important influence, occurring more frequently
in girls and being often associated with endocarditis. Of 140 cases of chorea
which I examined at a period more than two j^ears subsequent to the attack,
72 had signs of organic heart-disease, among which were 24 instances with the
physical signs of mitral stenosis. Anaemia and chlorosis, which are prevalent
in girls, have been regarded as possible factors. In a surprising number of
cases no recognizable etiological factor can be discovered. This has been re-
garded by some writers as favoring the view that many cases are of congenital
origin ; but it is not improbable that with any of the febrile affections of child-
hood endocarditis may be associated. Whooping-cough, too, with its terrible
strain on the heart-valves, may be accountable for certain cases. Congenital
affections of the mitral valve are notoriously rare. While met with at all
ages, stenosis is certainly more frequent in young persons.
Morbid Anatomy. — With the stenosis there is always some incompetency.
The narrowing results from thickening and contraction of the tissues of the
ring, of the valve segments, and of the chordae tendinese. The condition varies
a good deal according to the amount of atheromatous change. In many cases
the curtains are so welded together and the whole valvular region so thickened
that the orifice is reduced to a mere chink — Corrigan's button-hole contraction.
In other cases the curtains are not much thickened, but narrowing has resulted
Irom gradual adhesion at the edges, and thickening of the chordae tendineae,
50 that from the auricle it looks cone-like — the so-called funnel-shaped variety
of stenosis. The instances in which the valve segments are very slightly de-
formed, but in which the orifice is considerably narrowed, are regarded by
Bome as possibly of congenital origin. Occasionally the curtains are in great
part free from disease, but the narrowing results from large calcareous masses,
which project into them from the ring. The involvement of the chordae
tendinese is usually extreme, and the papillary muscles may be inserted directly
upon the valve. In moderate grades of constriction the orifice will admit the
tip of the index-finger; in more extreme forms, the tip of the little finger;
and occasionally one meets with a specimen in which the orifice seems almost
DISEASES OF THE HEART. 809
obliterated, admitting only a medium-sized Bowman's probe. The heart is
not greatly enlarged, rarely weighing more than 14 or 15 ounces. Occasion-
ally, in an elderly person, it may seem only slightly, if at all, enlarged, and
again there are instances in which the weight may reach as much as 20
ounces. The left ventricle is usually small, and may look very small in com-
parison with the right ventricle, which forms the greater portion of the apex.
In cases in which with the narrowing there is very considerable incompetency
the left ventricle may be moderately dilated and hypertrophied.
It is not uncommon at the examination to find white thrombi in the
appendix of the left auricle. Occasionally a large part of the auricle is occu-
pied by an ante-mortem thrombus. Still more rarely the remarkable ball
thrombus is found, in which a globular concretion, varying in size from a
walnut to a small egg, lies free in the auricle, two examples of which have
come under my observation.
The left auricle discharges its blood with greater difficulty and in conse-
quence dilates, and its walls reach three or four times their normal thickness.
Although the auricle is by structure unfitted to compensate an extreme lesion,
the probability is that for some time during the gradual production of stenosis,
the increasing muscular power of the walls is sufficient to counterbalance the
defect. In 36 cases of well-marked stenosis Samways found the auricle hyper-
trophied in 26, dilatation coexisting in 14. Eventually the tension is increased
in the pulmonary circulation, owing to impeded outflow from the veins and
this to heightened pressure in the pulmonary artery. Extra work is thus
thrown on the right ventricle, which gradually hypertrophies. Eelative incom-
petency of the tricuspid and congestion of the systemic veins at last supervene.
Symptoms. — Physical Signs. — Inspection. — In children the lower ster-
num and the fifth and sixth left costal cartilages are often prominent, owing
to hypertrophy of the right ventricle. The apex beat may be ill-defined. Usu-
ally, it is not dislocated far beyond the nipple line, and the chief impulse is
over the lower sternum and adjacent costal cartilages. Often in thin-chested
persons there is pulsation in the third and fourth left interspaces close to
the sternum. When compensation fails, the prsecordial impulse is much
feebler, and in the veins of the neck there may be marked systolic regurgi-
tation or the right jugular near the clavicle may stand out as a prominent
tumor. In the later stage, there is great enlargement with pulsation of the
liver.
Palpation reveals in a majority of the cases a characteristic, well-defined
fremitus or thrill, which is best felt, as a rule, in the fourth or fifth inter-
space within the nipple line. It is of a rough, grating quality, often pecul-
iarly limited in area, most marked during expiration, and can be felt to ter-
minate in a sharp, sudden shock, synchronous with the impulse. This most
characteristic of physical signs is pathognomonic of narrowing of the mitral
orifice, and is perhaps the only instance in which the diagnosis of a valvular
lesion can be made by palpation alone. The cardiac impulse is felt most for-
cibly in the lower sternum and in the fourth and fifth left interspaces. The
impulse is felt very high in the third and fourth interspaces, or in rare cases
even in the second, and it has been thought that in the latter interspace the
impulse is due to pulsation of the auricle. It is always the impulse of the
conus arteriosus of the right ventricle; even in the most extreme grades of
810 DISEASES OF THE CIRCULATORY SYSTEM.
mitral stenosis, there is never sncli tilting forward of the auricle or its appen-
dix as would enable it to produce an impression on the chest wall.
Percussion gives an increase in the cardiac dulness to the right of the
sternum and along the left margin; not usually a great increase beyond the
nipple line, except in extreme cases, when the transverse dulness may reach
from 5 cm. beyond the right margin of the sternum to 10 cm. beyond the
nipple line.
Auscultation. — To the inner side of the apex beat, often in a very limited
region, there is heard a. rough, vibratory or purring murmur, cumulative or
crescendo in character, which terminates abruptly in the first sound. By
combining palpation and auscultation the purring murmur is found to be syn-
chronous with the thrill and the loud shock with the first sound. The mur-
mur is auricular systolic, due to the blood passing through the narrow orifice.
Some have thought it to be early systolic in time, but the majority of observers
hold to the former view with Gairdner. The presystolic murmur may occupy
the entire period of the diastole, or the middle or onl}^ the latter half, corre-
sponding to the auricular systole. The difference may sometimes be noted
between the first and second portions of the murmur, when it occupies the
jentire time. Often there is a peculiar rumbling or echoing quality, which in
some instances is very limited and may be heard only over a single bell-space
of the stethoscope. A rumbling, echoing presystolic murmur at the apex is
heard in some cases of aortic insufficiency (Flint murmur), occasionally in
adherent pericardium with great dilatation of the heart and in upward dis-
location of the organ.
A systolic murmur may be heard at the apex or along the left sternal
border, often of extreme softness and audible only when the breath is held.
Sometimes the systolic murmur is loud and distinct and is transmitted to
the axilla. The second sound in the second left interspace is loudly accentu-
ated, and often reduplicated. It may be transmitted far to the left and be
heard with great clearness beyond the apex. In uncomplicated cases of mitral
stenosis there are usually no murmurs audible at the aortic region, at which
spot the second sound is less intense than at the pulmonary area. In advanced
cases at the lower sternum and to the right a systolic tricuspid murmur is
sometimes heard. Other points to be noted are the following : The unusually
sharp, clear first sound which follows the presystolic murmur, the cause of
which is by no means easy to explain. It can scarcely be a valvular sound
produced chiefly at the mitral orifice, since it may be heard with great intensity
in cases in which the valves are rigid and calcified. It has been suggested by
A. E. Sansom and others that it is a loud " snap " of the tricuspid valves
caused by the powerful contraction of the greatly hypertrophied right ven-
tricle. Broadbent thinks it may be due to the abrupt contraction of a partially
filled left ventricle. The valvular sound may be audible at a distance, as one
sits at the bedside of the patient (Graves). In a patient I saw with Dr. C. J.
Blake the first sound was audible six feet, by measurement, from the chest wall.
These physical signs, it is to be borne in mind, are characteristic only
of the stage in which compensation is maintained. The murmur may be
soft, almost inaudible, and only brought out after exertion. Finally there
comes a period in which, with failure of compensation, the presystolic mur-
mur disappears and there is heard in the apex region a sharp first sound, or
DISEASES OF THE HEART. 811
sometimes a gallop rhythm. The marked systolic shock may be present after
the disappearance of the thrill and the characteristic murmur. Under treat-
ment, with gradual recovery of compensation, probably with increasing vigor
of contraction of the right ventricle and left auricle, the presystolic murmur
reappears. In cases seen at this stage of the disease the nature of the valve
lesion may be entirely overlooked.
Stenosis of the mitral valve may for years be efficiently compensated by
the hypertrophy of the right ventricle. Many persons with the characteristic
physical signs of this lesion present no symptoms. They may for years per-
haps be short of breath on going upstairs, but are able to pass through the
ordinary duties of life without discomfort. The pulse is smaller in volume
than normal, and very often irregular. A special danger of this stage is the
recurring endocarditis. Vegetations may be whipped off into the circulation
and, blocking a cerebral vessel, may cause hemiplegia or aphasia, or both.
This, unfortunately, is not an uncommon sequence in women. Patients with
mitral stenosis may survive this accident for an indefinite period. A woman,
above seventy years of age, died in one of my wards at the Philadelphia Hos-
pital, who had been in the almshouse, hemiplegic, for more than thirty years.
The heart presented an extreme grade of mitral stenosis which had probably-
existed at the time of the hemiplegic attack.
Pressure of the enlarged auricle on the left recurrent laryngeal nerve,
causing paralysis of the vocal cord on the corresponding side, has been de-
scribed by Ortner and by Herrick. I have met with two instances. It is a
point to be borne in mind, as the diagnosis of aneurism of the arch of the
aorta may be made.
Failure of compensation brings in its train the group of symptoms which
have been discussed under mitral insufficiency. Briefly enumerated they are :
Rapid and irregular action of the heart, shortness of breath, cough, signs of
pulmonary engorgement, and very frequently hfemoptysis. Attacks of this
kind may recur for years. Bronchitis or a febrile attack may cause shortness
of breath or slight blueness. Inflammatory affections of the lungs or pleura
seriously disturb the right heart, and these patients stand pneumonia very
badly. Many, perhaps a majority of cases of mitral stenosis, do not have
dropsy. The liver may be greatly enlarged, and in the late stages ascites is
not uncommon, particularly in children. General anasarca is most frequently
met with in those cases in which there is secondary narrowing of the tricuspid
orifice (Broadbent).
6. Tricuspid Valve Disease.
(a) Tricuspid Regurgitation. — Occasionally this results from acute or
chronic endocarditis with puckering; more commonly the condition is one
of relative insufficiency, and is secondary to lesions of the valves on the left
side, particularly of the mitral. It is met with also in all conditions of the
lungs which cause obstruction to the circulation, such as cirrhosis and emphy-
sema, particularly in combination with chronic bronchitis. The symptoms are
those of obstruction in the lesser circulation with venous congestion in the sys-
temic veins, such as has already been described in connection with mitral
insufficiency. The signs of this condition are:
(1) Systolic regurgitation of the blood into the right auricle and the
812 DISEASES OF THE CIRCULATORY SYSTEM.
transmission of the pulse-wave into the veins of the neck. If the regurgitation
is slight or the contraction of the ventricle is feeble there may be no venous
throbbing, but in other cases there is marked systolic pulsation in the cervical
veins. That in the right jugular is more forcible than that in the left. It may
be seen both in the internal and the external vein, particularly in the latter.
Marked pulsation in these veins occurs only when the valves guarding them
become incompetent. Slight oscillations are by no means uncommon, even
when the valves are intact. The distention is sometimes enormous, particu-
larly in the act of coughing, when the right jugular at the root of the neck
may stand out, forming an extraordinary prominent ovoid mass. Occasionally
the regurgitant pulse-wave may be widely transmitted and be seen in the sub-
clavian and axillary veins, and even in the subcutaneous veins over the shoul-
der, or in the superficial mammary veins.
Eegurgitant pulsation through the tricuspid orifice may be transmitted
to the inferior cava, and so to the hepatic veins, causing a systolic distention
of the liver. This is best appreciated by bimanual palpation, placing one hand
over the fifth and sixth costal cartilages and the other in the lateral region
of the liver in the mid-axillary line. The rhythmical expansile pulsation may
be readily distinguished, as a rule, from the systolic depression of the liver
due to communicated pulsation from the left ventricle.
(2) The second important sign of tricuspid regurgitation is the occur-
rence of a systolic murmur of maximum intensity in the lower sternum. It
is usually a soft, low murmur, often to be distinguished from a coexisting
mitral murmur by differences in quality and pitch, and may be heard to the
right as far as the axilla. Sometimes it is very limited in its distribution.
Together these two signs positively indicate tricuspid regurgitation. In
addition, the percussion usually shows increase in the area of dulness to the
right of the sternum, and the impulse in the lower sternal region is forcible.
In the great majority of cases the symptoms are those of the associated lesions.
In cirrhosis of the lung and in chronic emphysema the failure of compensation
of the right ventricle with insufficiency of the tricuspid not infrequently leads
either to acute asystole or to gradual failure with cardiac dropsy.
(&) Tricuspid Stenosis. — This interesting condition may be either con-
genital or acquired. The congenital cases are not uncommon, and are asso-
ciated usually with other valvular defects which cause early death. The
acquired form is not very infrequent. Bedford Fenwick collected 46 observa-
tions, of which 41 were in women. Leudet has analyzed 117 cases. Of 101
of these in which the ages were mentioned, 80 were in women and 21 in men.
A great majority of the cases were in adults, only 8 being between the ages
of ten and twenty. Its rarity as an isolated condition may be gathered from
the fact that of 114 autopsies, in 11 only was the lesion confined to this valve.
In 21 the tricuspid, mitral, and aortic segments were involved, and in 78 the
tricuspid and mitral. Practically the condition is almost always secondary
to lesions of the left heart.
The physical signs are sometimes characteristic. For instance, a pre-
systolic thrill has been noted by several observers. The percussion shows
dulness to be increased, particularly to the right of the sternum. On aus-
cultation a presystolic murmur has been determined in certain cases, and
is heard best at the root of the ensiform cartilage, or a little to the right of
DISEASES OF THE HEART. 813
it. Of general symptoms, cyanosis of the face and lips is very common, and
in the late stages, when dropsy supervenes, it is apt to be intense. The lesion
is interesting chiefly because it forms one of the most serious complications of
mitral stenosis.
7. Pulmonary Valve Disease.
Murnmrs in the region of the pulmonary valves are extremely common;
lesions of the valves are exceedingly rare. Balfour has well called the pul-
monic area the region of auscultatory romance. A systolic murmur is heard
here under many conditions — (1) very often in health, in thin-chested persons,
particularly in children, during expiration and in the recumbent posture; (2)
when the heart is acting rapidly, as in fever and after exertion; (3) it is a
favorite situation of the cardio-respiratory murmur; (4) in anaemic states;
and (5) as mentioned previously, the systolic murmur of mitral insufficiency
may be transmitted along the left sternal margin. Actual lesions of the valves
of the pulmonary artery are rare.
(a) Stenosis is almost invariably a congenital anomaly. It constitutes
one of the most important of the congenital cardiac affections. The valve
segments are usually united, leaving a small, narrow orifice. In adults cases
occasionally occur. The congenital lesion is commonly associated with patency
of the ductus Botali and imperfection of the ventricular septum. There may
also be tricuspid stenosis. Acute endocarditis not infrequently attacks the
sclerotic valves.
The physical signs are extremely uncertain. There may be a systolic mur-
mur with a thrill heard best to the left of the sternum in the second inter-
costal space. This murmur may be very like a murmur of aortic stenosis, but
is not transmitted into the vessels. ISTaturally the pulmonary second sound is
weak or obliterated, or may be replaced by a diastolic murmur. Usually there
is hypertrophy of the right heart.
(6) Pulmonary Insufficiency. — This rare affection is occasionally due to
congenital malformation, particularly fusion of two of the segments. It is
sometimes present, as Bramwell has shown, in cases of malignant endocar-
ditis. Barie has collected 58 cases.
The physical signs are those of regurgitation into the right ventricle,
but, as a rule, it is difficult to differentiate the murmur from that of aortic
insufficiency, though the maximum intensity may be in the pulmonary area.
The absence of the vascular features of aortic insufficiency is suggestive.
Both Gibson and Graham Steell have called attention to the possibility of leak-
age through these valves in cases of great increase of pressure in the pulmonary
artery, and to a soft diastolic murmur heard under these circumstances, which
Steell calls " the murmur of high pressure in the pulmonary artery."
8. Combined Valvular Lesions.
Valvular lesions are seldom single or pure; combined lesions are more
common. This is particularly the case in congenital disease. In young chil-
dren mitral and aortic lesions, the result of rheumatic fever, are common.
Pure mitral insufficiency and pure mitral stenosis may exist for years, but
in time the tricuspid becomes involved, at first in sclerosis and later narrowing
of the orifice. Aortic valve lesions are more commonly uncombined than
814 DISEASES OF THE CIRCULATORY SYSTEM.
mitral lesions. The added lesion may be hurtful or helpful. The stenosis
which so often accompanies the endocarditic variety may lessen the regurgi-
tation in aortic insufficiency; and a progressive narrowing of the mitral orifice
may be beneficial in mitral regurgitation.
Prognosis in Valvular Disease. — The question is entirely one of efficient
compensation. So long as this is maintained the patient may suffer no incon-
venience, and even with the most serious forms of valve lesion the function of
the heart may be little, if at all, disturbed.
Practitioners who are not adepts in auscultation and feel unable to esti-
mate the value of the various heart murmurs should remember that the best
Judgment of the conditions may be gathered from inspection and palpation.
With an apex beat in the normal situation and regular in rhythm the auscul-
tatory phenomena may be practically disregarded.
A murmur per se is of little or no moment in determining the prognosis
in any given case. There is a large group of patients who present no other
symptoms than a systolic murmur heard over the body of the heart, or over
the apex, in whom the left ventricle is not hypertrophied, the heart rhythm is
normal, and who may not have had rheumatism. Indeed, the condition is
accidentally discovered, often during examination for life insurance. Among
the conditions influencing prognosis are :
(a) Age. — Children under ten are bad subjects. Compensation is well
effected, and they are free from many of the influences which disturb com-
pensation in adults. The coronary arteries are healthy, and nutrition of the
heart-muscle can be readily maintained. Yet, in spite of this, the outlook in
cardiac lesions developing in very young children is usually bad. One reason
is that the valve lesion itself is apt to be rapidly progressive, and the limit of
cardiac reserve force is in such cases early reached. There seems to be pro-
portionately a greater degree of hypertrophy and dilatation. Among other
causes of the risks of this period are to be mentioned insufficient food in the
poorer classes, the recurrence of rheumatic attacks, and the existence of peri-
cardial adhesions. The outlook in a child who can be carefully supervised
and prevented from damaging himself by overexertion is naturally better than
in one who is constantly overtasking his muscles. The valvular lesions which
occur at, or subsequent to, the period of puberty are more likely to be perma-
nently and efficiently compensated. Sudden death from heart-disease is very
rare in children.
(&) Sex. — Women bear valve lesions, as a rule, better than men, owing
partly to the fact that they live quieter lives, partly to the less common involve-
ment of the coronary arteries, and to the greater frequency of mitral lesions.
Pregnancy and parturition are disturbing factors, but are, I think, less serious
than some writers would have us believe.
( c) Valve Affected. — The relative prognosis of the different valve lesions
is very difficult to estimate. Each case must, therefore, be judged on its own
merits. 4ortic insufficiency is unquestionably the most serious; yet for years
it may be perfectly compensated. Favorable circumstances in any case are
the moderate grade of hypertrophy and dilatation, the absence of all symptoms
of cardiac distress, and the absence of extensive arterio-sclerosis and of angina.
The prognosis rests in reality with the condition of the coronary arteries.
Kheumatic lesions of the valves, inducing insufficiency, are less apt to be asso-
DISEASES OF THE HEART. 815
ciated with endarteritis at the root of the aorta ; and in sucli cases the coronary
arteries may escape for years. On the other hand, when the aortic insufficiency
is only a part of an extensive arterio-sclerosis at tlie root of the aorta, the coro-
nary arteries are almost invariably involved, and the outlook in such cases is
much more serious. Sudden death is not uncommon, either from acute dila-
tation during some exertion, or, more frequently, from blocking of one of the
branches of the coronary arteries. The liability of this form to be associated
with angina pectoris also adds to its severity. Aortic stenosis is a compara-
tively rare lesion, most commonly met with in middle-aged or elderly men,
and is, as a rule, well compensated. In Broadbent's series of cases, in which
autopsy showed definite aortic narrowing, forty years was the average age at
death, and the oldest was but fifty-three.
In mitral lesions the outlook on the whole is much more favorable than
in aortic insufficiency. Mitral insufficiency, when well compensated, carries
with it a better prognosis than mitral stenosis. Except aortic stenosis, it is
the only lesion commonly met with in patients over threescore years. It must
be borne in mind that the cases which last the longest are those in which the
valve orifice is more or less narrowed, as well as incompetent. There is, in
reality, no valve lesion so poorly compensated and so rapidly fatal as that in
which the mitral segments are gradually curled and puckered until they form
a narrow strip around a wide mitral ring — a condition specially seen in chil-
dren. There are many cases of mitral insufficiency in which the defect is
thoroughly balanced for thirty or even forty years, without distress or incon-
venience. Even with great hypertrophy and the apex beat almost in the mid-
axillary line, there may be little or no distress, and the compensation may be
most effective. Women may pass safely through repeated pregnancies, though
here they are liable to accidents associated with the severe strain. I have had
under observation for many years a patient who had her first attack of rheuma-
tism at the age of fifteen, when she already had a well-marked mitral murmur.
She first came under my observation, thirty-three years ago, with signs of
hypertrophy of the left ventricle and a loud systolic murmur. She has lived
a very active life, has been unusually vigorous, has borne eleven children, and
has passed through three subsequent attacks of rheumatism. She is now in
her sixty-third year. The loud mitral systolic murmur persists, but she is
very well, only a little short of breath on exertion.
In mitral stenosis the prognosis is usually regarded as less favorable. My
own experience has led me, however, to place this lesion almost on a level, par-
ticularly in women, with the mitral insufficiency. It is found very often in
persons in perfect health, who have had neither palpitation nor signs of heart-
failure, and who have lived laborious lives. The figures given, too, by Broad-
bent indicate that the date of death in mitral stenosis is comparatively ad-
vanced. Of 53 cases abstracted from the post-mortem records of St. Mary's
Hospital, thirty-three was the age for males, and thirty-seven or thirty-eight
for females. These women, too, pass through repeated pregnancies with safety.
There are of course those too common accidents, the result of cerebral embol-
ism, which are more likely to occur in this than in other forms.
Hard and fast lines caa not be drawn in the question of prognosis in
valvular disease. Every case must be judged separately, and all the circum-
stances carefully balanced. There is no question which requires greater expe-
816 DISEASES OF THE CIRCULATORY SYSTEM.
rience and more mature judgment, and even the most experienced are some-
times at fault.
The following conditions justify a favorable prognosis: Good general
health and good habits; no exceptional liability to rheumatic or catarrhal
affections; origin of the valvular lesion independently of degeneration; exist-
ence of the valvular lesion without change for over three years; sound ven-
tricles, of moderate frequency and general regularity of action ; sound arteries,
vrith a normal amount of blood and tension in the smaller vessels ; and, lastly,
freedom from pulmonary, hepatic, and renal congestion.
Treatment of Valvular Lesions. — (a) Stage of Compexsatio^j". — Medici-
nal treatment at this period is not necessary and is often hurtful. A very
common error is to administer cardiac drugs, such as digitalis, on the discov-
ery of a murmur or of hypertrophy. If the lesion has been found accidentally,
it may be best not to tell the patient, but rather an intimate friend. Often
it is necessary, however, to be perfectly frank in order that the patient may
take certain preventive measures. He should lead a quiet, regulated, orderly
life, free from excitement and worry, and the risk of sudden death makes it
imperative that the patient suffering from aortic disease should be specially
warned against overexertion and hurry. An ordinary wholesome diet in mod-
erate quantities should be taken; tobacco may be allowed in moderation, but
stimulants should be interdicted or used in very small amount. Exercise
should be regulated entirely by the feelings of the patient. So long as no
cardiac distress or palpitation follows, moderate exercise will prove very bene-
ficial. The skin should be kept active by a daily bath. Hot baths should be
avoided and the Turkish bath should be interdicted. In the case of full-
blooded, somewhat corpulent individuals, an occasional saline purge should be
taken. Patients with valvular lesions should not go into very high altitudes.
The act of coition has serious risks, particularly in aortic insufficiency. Know-
ing that the causes which most surely and powerfully disturb the compensation
are overexertion, mental worry, and malnutrition, the physician should give
suitable instructions in each case. As it is always better to have the co-opera-
tion of an intelligent patient, he should, as a rule, be told of the condition,
but in this matter the physician must be guided by circumstances, and there
are cases in which reticence is the wiser policy.
(&) Stage of Broken Compensation. — The break may be immediate and
final, as when sudden death results from acute dilatation or from blocking of
a branch of the coronary artery, or it may be gradual. Among the first indi-
cations are shortness of breath on exertion or attacks of nocturnal dyspnoea.
These are often associated with impaired nutrition, particularly with angemia,
and a course of iron or change of air may suffice to relieve the s}Tnptoms.
Irregularity of the action of the heart can not always be termed an in-
dication of failing compensation, particularly in instances of mitral disease.
It has greater significance in aortic lesions. Serious failure of compensation
is indicated by signs of dilatation of the heart, marked cyanosis, the gallop
rhythm, or various forms of arrhj^thmia, with or without the existence of
dropsy. Under these circumstances the following measures are to be carried
out: .
(1) Rest. — Disturbed compensation may be completely restored by rest
of the body. In many cases with cedema of the ankles, moderate dilatation of
DISEASES OF THE HEART. 817
the heart, and irregularity of the pulse, the rest in bed, a few doses of the
compound tincture of cardamoms, and a saline purge suffice, within a week or
ten days, to restore the compensation.
(2) The relief of the embarrassed circulation.
(a) By Venesection. — In cases of dilatation, from whatever cause, whether
in mitral or aortic lesions or distention of the right ventricle in emphysema,
when signs of venous engorgement are marked and when there is orthopnoea
with cyanosis, the abstraction of from 20 to 30 ounces of blood is indicated.
This is the occasion in which timely venesection may save the patient's life.
It is particularly helpful in the dilated heart of arterio-sclerosis.
(&) By Depletion through the Bowels. — This is particularly valuable when
dropsy is present. Of the various purges the salines are to be preferred, and
may be given by Matthew Hay's method. Half an hour to an hour before
breakfast from half an ounce to an ounce and a half of Epsom salts may be
given in a concentrated form. This usually produces from three to five liquid
evacuations. The compound jalap powder in half -drachm doses, or elaterium,
may be employed for the same purpose. Even when the pulse is very feeble
these hydragogue cathartics are well borne, and they deplete the portal system
rapidly and efficiently.
(c) The Use of Remedies which stimulate the Heart's Action. — Of these,
by far the most important is digitalis, which was introduced into practice
by Withering. The indication for its use is weakness of the heart-muscle ; the
contra-indication is a perfectly balanced compensatory hypertrophy, such as
we see in all forms of valvular disease. Broken coriipensation, no matter what
the valve lesion may be, is the signal for its use. It acts upon the heart, slow-
ing and at the same time increasing the force of the contractions. It acts
on the peripheral arteries, raising their tension, so that a steady and equable
flow of blood is maintained in the capillaries, which, after all, is the prime
aim and object of the circulation. The beneficial effects are best seen in cases
of mitral disease with small, irregular pulse and cardiac dropsy. Its effects
are not less striking in the dilatation of the left ventricle, in the failing com-
pensation of aortic insufficiency or of arterio-sclerosis. On theoretical grounds
it has been urged that its use is not so advantageous in aortic insufficiency,
since it prolongs the diastole and leads to greater distention. This need not
be considered, and digitalis is just as serviceable in this as in any other con-
dition associated with progressive dilatation; larger doses are often required.
It may be given as the tincture or the infusion. In cases of cardiac dropsy,
from whatever cause, 15 minims of the tincture or half an ounce of the in-
fusion may be given every three hours for two days, after which the dose may
be reduced. Some prefer the tincture, others the infusion; it is a matter of
indifference if the drug is good. The urine of a patient taking digitalis should
be carefully estimated each day. As a rule, when its action is beneficial, there
is within twenty- four hours an increase in the amount; often the flow is very
great. Under its use the dyspnoea is relieved, the dropsy gradually disappears,
the pulse becomes firmer, fuller in volume, and sometimes, if it has been very
intermittent, regular.
Ill effects sometimes follow digitalis. There is no such thing as a cumu-
lative action of the drug manifested by sudden symptoms. Toxic effects are
seen in the production of nausea and vomiting. The pulse becomes irregular
53
818 DISEASES OF THE CIRCULATORY SYSTEM.
and small, and there may be t^vo beats of the heart to one of the pulse, which,
as pointed out by Broadbent, is found particularly in cases of mitral stenosis
when they are under the influence of this drug. The urine is reduced in
amount. These sjmiptoms subside on the withdrawal of the digitalis, and are
rarely serious. There are patients who take digitalis uninterruptedly for
years, and feel palpitation and distress if the drug is omitted. In mitral dis-
ease, even when it does good it does not always steady the pulse. There are
many cases in which the irregularity is not affected by the digitalis. When
the compensation has been re-established the drug may be omitted. When
there is dyspnoea on exertion and cardiac distress, from 5 to 10 minims three
times a day may be advantageously given for prolonged periods, but the effects
should be carefully watched. In cardiac dropsy digitalis should be used at the
outset with a free hand. . Small doses should not be given, but from the first
half-ounce doses of the infusion every three hours, or from 15 to 20 minims of
the tincture. Digitalin, hypodermic ally (gr. -^), every three or four hours,
may be substituted.
Of other remedies strophanthus alone is of service. Given in doses of from
5 to 8 minims of the tincture, it acts like digitalis. It certainly will sometimes
steady the intermittent heart of mitral valve disease when digitalis fails to do
so, but it is not to be compared with this drug when dropsy is present. Conval-
laria, citrate of caffeine, and adonis vernalis and sparteine are warmly recom-
mended as substitutes for digitalis, but their inferiority is so manifest that
their use is rarely indicated.
There are two valuable adjuncts in the treatment of valvular disease — iron
and strychnia. When anaemia is a marked feature iron should be given in
full doses. In some instances of failing compensation this is the only medi-
cine needed to restore the balance. Arsenic is occasionally an excellent substi-
tute, and one or other of them should be administered in all instances of heart-
trouble when pallor is present. Stryclinia is a heart tonic of very great value.
It may be given alone or in combination with the digitalis in 1 or 2 drop doses
of the l-per-cent solution, or M^odermically in doses of -^-y^Q-gr. Alcoholic
stimulants in moderation are occasionally useful, especially in tiding over a
period of acute cardiac weakness.
Treatment of Special Symptoms. — (a) Dropsy. — The increased arterial
tension and activity of the capillary circulation under the influence of digitalis
hastens the interstitial hinph flow and favors resorption of the fluid. The
hydragogue cathartics, by rapidly depleting the blood, promote, too, the absorp-
tion of the fluid from the lymph spaces and the lymph sacs. These two meas-
ures usually suffice to rid the patient of the dropsy. In some cases, however,
it can not be relieved, and then Southej^'s tubes may be used or the legs punc-
tured. If done with care, after a thorough washing of the parts, and if anti-
septic precautions are taken, scarification is a very serviceable measure, and
should be resorted to more frequently than it is. Canton flannel bandages may
be applied on the cedematous legs.
(&) Dtspxcea. — The patients are usually unable to lie down. A comfort-
able bed-rest should therefore be provided — if possible, one with lateral projec-
tions, so that in sleeping the head can be supported as it falls over. The
shortness of breath is associated with dilatation, chronic bronchitis, or hydro-
thorax. The chest should be carefully examined in all these cases, as hydro-
DISEASES OF THE HEART. 819
thorax of one side or of both is a common cause of shortness of breath.
There are cases of mitral regurgitation with recurring hydrothorax usually
on the right side, which is relieved, week by week or month by month, by
tapping. For the nocturnal dyspnoea, particularly when combined with rest-
lessness, morphia is invaluable and may be given without hesitation. ,, The
value of the calming influence of opium in all conditions of cardiac insuf-
ficiency is not sufficiently recognized. There are instances of cardiac dyspnoea
unassociated with dropsy, particularly in mitral valve disease, in which nitro-
glycerin is of great service, if given in the 1-per-cent solution in increasing
doses. It is especially serviceable in the cases in which the pulse tension is
high.
(c) Palpitation and Cardiac Distress. — In instances of great hyper-
trophy and in the throbbing which is so distressing in some cases of aortic in-
sufficiency, aconite is of service in doses of from 1 to 3 minims every two or
three hours. An ice-bag over the heart or Leiter's coil is also of service in
allaying the rapid action and the throbbing. For the pains, which are often
so marked in aortic lesions, iodide of potassium in 10-grain doses, three times
a day, or the nitroglycerin may be tried. Small blisters are sometimes advan-
tageous. It must be remembered that an important cause of palpitation and
cardiac distress is flatulent distention of the stomach or colon, against which
suitable measures must be directed.
(d) Gastric Symptoms. — The cases of cardiac insufficiency which do
badly and fail to respond to digitalis are most often those in which nausea
and vomiting are prominent features. The liver is often greatly enlarged in
these cases; there is more or less stasis in the hepatic vessels, and but little
can be expected of drugs until the venous engorgement is relieved. If the
vomiting persists, it is best to stop the food and give small bits of ice, small
quantities of milk and lime water, and effervescing drinks, such as Apol-
linaris water and champagne. Creasote, hydrocyanic acid, and the oxalate of
cerium are sometimes useful; but, as a rule, the condition is obstinate and
always serious.
(e) Cough and Hemoptysis. — The former is almost a necessary con-
comitant of cardiac insufficiency, owing to engorgement of the pulmonary ves-
sels and more or less bronchitis. It is allayed by measures directed rather to
the heart than to the lungs. Hemoptysis in chronic valvular disease is some-
times a salutary symptom. An army surgeon, who was invalided during the
American civil war on account of hsemoptysis, supposed to be due to tuber-
culosis, had for many years, in association with mitral insufficiency and en-
larged heart, many attacks of hasmoptysis. He assured me that his condition
was invariably better after the attack. It is rarely fatal, except in some cases
of acute dilatation, and seldom calls for special treatment.
(/) Sleeplessness. — One of the most distressing features of valvular
lesions, even in the stage of compensation, is disturbed sleep. Patients may
wake suddenly with throbbing of the heart, often in an attack of nightmare.
Subsequently, Avhen the compensation has failed, it is also a worrying symp-
tom. The sleep is broken, restless, and frequently disturbed by frightful
dreams. Sometimes a dose of the spirits of chloroform or of ether, with half
a drachm of spirits of camphor, given in a little hot whisky, will give a quiet
night. The compound spirits of ether, Hoffmann's anodyne, though very un-
820 DISEASES OF THE CIRCULATORY SYSTEM.
pleasant to take, is frequently a great boon in the intermediate period when
compensation has partially failed and the patients sufEer from restless and
sleepless nights. Paraldehyde and amylene hydrate are sometimes serviceable.
Urethan, sulphonal, and chloralamide are rarely efficacious, and it is best, after
a few trials, particularly if the paraldehyde does not answer, to resort to
morphia. It may be given in combination with atropine.
(g) Eenal Symptoms. — With broken compensation and lowering of
the tension in the aorta, the urinary secretion is greatly diminished, and
the amount may sink to 5 or 6 ounces in the day. Digitalis, and strophan-
thus when efficient, usually increase the flow. A brisk purge may be followed
by augmented secretion. The combination in pill form of digitalis, squill,
and the black oxide of mercury, will sometimes prove eflective when the infu-
sion or tincture -of digitalis alone has failed. Calomel acts well in some cases,
given in S-grain doses every six hours for three or four days.
The DIET in chronic valve-diseases is often very difficult to regulate. Widal
and others have shown that retention of the chlorides is an important factor
in cardiac dropsy and heart failure. A milk diet, 3 liters a day, favors their
elimination, and in the intervals between attacks a salt-free diet as far as
possible should be used. Starchy foods, and all articles likely to cause flatu-
lency, should be forbidden. Stimulants are often necessary, either whisky or
brandy.
III. AFFECTIONS OF THE MYOCARDIUM.
1. Dilatation and Hypeeteophy,
As with other muscular hollow organs, the size of the chambers of the
heart varies greatly within normal limits. Dilatation may be an acute process,
and quite transitory as after severe muscular effort, or it may be chronic, in
which case it is associated with hypertrophy. Kot always, however; there is
an extraordinary heart in the McGill College Museum showing a parchment-
like thinning of the walls with uniform dilatation of all the chambers; in
places in the right auricle and ventricle only the epicardium remains. Dila-
tation is pathological only when permanent. Increase in capacity means
increased work for the walls, which in consequence hypertrophy to meet the
demand.
Dilatation. — Two important causes combine to produce dilatation — in-
creased pressure within the cavities and impaired resistance, due to weakening
of the muscular wall — which may act singly, but are often combined. A
weakened wall may yield to a normal distending force, or a normal wall may
yield under a heightened blood-pressure.
(1) Heightened endocaediac peessuee results either from an increased
quantity of blood to be moved or an obstacle to be overcome, and is the more
frequent cause. It does not necessarily bring about dilatation; simple hyper-
trophy may follow, as in the early period of aortic stenosis, and in the hyper-
trophy of the left ventricle in Bright's disease.
The size of the cardiac chambers varies in health. With slow action of
the heart the dilatation is complete and fuller than it is with rapid action.
Physiologically, the limits of dilatation are reached when the chamber does
not empty itself during the systole. This may occur as an acute, transient con-
DISEASES OF THE HEART. 821
dition in severe exertion— during, for example, the ascent of a mountain.
There may be great dilatation of the right heart, as shown by the increased
epigastric pulsation, and even increase in the cardiac dulness. The safety-
valve action of the tricuspid valves may here come into play, relieving the
lungs by permitting regurgitation into the auricle. With rest the condition
is removed, but if it has been extreme, the heart may suffer a strain from
which it may recover slowly, or, indeed, the individual may never be able
again to undertake severe exertion. In the process of training, the getting
wind, as it is called, is largely a gradual increase in the capability of the
heart, particularly of the right chambers, A degree of exertion can be safely
maintained in full training which would be quite impossible under other cir-
cumstances, because, by a gradual process of what we may call physical edu-
cation, the heart has strengthened its reserve force — widened enormously its
limits of physiological work. Endurance in prolonged contests is measured
by the capabilities of the heart, and its essence consists in being able to meet'
the continuous tendency to overstep the limits of dilatation. We have no
positive knowledge of the nature of the changes in the heart which occur in
this process, but it must be in the direction of increased muscular and nervous
energy. The large heart of athletes may be due to the prolonged use of their
muscles, but no man becomes a great runner or oarsman who has not natu-
rally a capable if not a large heart. Master McGrath, the celebrated grey-
hound, and Eclipse, the race-horse, both famous for endurance rather than
speed, had very large hearts.
Excessive dilatation during severe muscular effort results in heart-strain.
A man, perhaps in poor condition, calls upon his heart for extra work during
the ascent of a high mountain, and is at once seized with pain about the heart
and a sense of distress in the epigastriuni. He breathes rapidly for some time,
is " puffed," as we say, but the symptoms pass off after a night's quiet. An
attempt to repeat the exercise is followed by another attack, or, indeed, an
attack of cardiac dyspnoea may come on while he is at rest. For months such
a man may be unfitted for severe exertion, or he may be permanently incapac-
itated. In some way he has overstrained his heart and become "broken-
winded." Exactly what has taken place in these hearts we can not say, but
their reserve force is lost, and with it the power of meeting the demands
exacted in maintaining the circulation during severe exertion. The " heart-
shock" of Latham includes cases of this nature — sudden cardiac breakdown
during exertion, not due to rupture of a valve. It seems probable that sudden
death in men during long-continued efforts, as in a race, is sometimes due to
overdistention and paralysis of the heart.
Acute dilatative heart weakness is seen in many conditions, as in Graves'
disease, in paroxysmal tachycardia, in old myocardial cases following exertion,
and in angina pectoris. There is usually a striking contrast between the wide
and forcible cardiac impulse and the small, feeble, irregular pulse.
Dilatation occurs in all forms of valve lesions. In aortic incompetency
blood enters the left ventricle during diastole from the unguarded aorta and
from the left auricle, and the quantity of blood at the termination of diastole
subjects the walls to an extreme degree of pressure, under which they inevitably
yield. In time they augment in thickness, and present the typical eccentric
hypertrophy of this condition.
822 DISEASES OF THE CIRCULATORY SYSTEM.
In mitral insufficiency blood which should have been driven into the aorta
is forced into and dilates the auricle from which it came, and then in the
diastole of the ventricle a large amount is returned from the auricle, and with
increased force. In mitral stenosis the left auricle is the seat of greatly in-
creased tension during diastole, and dilates as well as hj'pertrophies ; the dis-
tention, too, ma}' be enormous. Dilatation of the right ventricle is produced
by a number of conditions, which were considered under h3^ertrophy. All
circumstances, such as mitral stenosis, emphysema, etc., which permanently
increase the tension of the Ijlood in the pulmonary vessels, cause its dilatation.
The idiopathic dilatation and hj-pertrophy of beer drinkers also comes in
this group, as it is brought about gradually by increased endocardial pressure.
(2) Impaired xutritiox of the heart- walls may lead to a diminution
of the resisting power so that dilatation readily occurs.
The loss of tone due to parenchjinatous degeneration or myocarditis in
fevers may lead to a fatal condition of acute dilatation. It is a recognized
cause of death in scarlatinal dropsy (Goodhart), and may occur in rheumatic
fever, typhus, tj-phoid, erysipelas, etc. The changes in the heart-muscle which
accompany acute endocarditis or pericarditis may lead to dilatation, especially
in the latter disease. In ansemia, leuksemia, and chlorosis the dilatation
may be considerable. In sclerosis of the walls, the yielding is always where
this process is most advanced, as at the left apex. Under any of these cir-
cumstances the walls may yield with normal blood-pressure.
Pericardial adhesions are a cause of dilatation, and we generally find in
eases with extensive and firm union considerable hypertrophy and dilatation.
There is usually here some impairment as well of the superficial layers of
muscle.
Hypertrophy. — There are two forms of kypertropliy, one in which the
cavity or cavities are of normal size; and the other with dilatation (eccentric
hypertrophy), in which the cavities are enlarged and the walls increased in
thickness. The condition formerly spoken of as concentric hjqDertrophy, in
which there is diminution in the size of the cavity with tliickening of the
walls, is, as a rule, a post-mortem change.
The enlargement may affect the entire organ, one side, or only one cham-
ber. Xaturally, as the left ventricle does the chief work in forcing the blood
through the systemic arteries, the change is most frequently found in it.
H}"pertrophy of the heart follows the law governing muscles, that within
certain limits, if the nutrition is kept up, increased work is followed by
increased size — i. e., h3'pertrophy.
Htperteopht oe the left vextricle aloxe^ or with general enlarge-
ment of the heart, is brought about b}' —
Conditions affecting the lieart itself: (1) Disease of the aortic valve; (3)
mitralinsufficiency; (3) pericardial adhesions; (-4) sclerotic myocarditis ; (5)
disturbed innervation, with overaction, as in exophthalmic goitre, in long-
continued nervous palpitation, and as a result of the action of certain articles,
such as tea, coffee, and tobacco. In all of these the work of the heart is
increased. In the case of the valve lesions the increase is due to the increased
intraventricular pressure; in the case of the adherent pericardium and myo-
carditis, to direct interference with the symmetrical and orderly contraction of
the chambers.
DISEASES OF THE HEART. 823
Conditions acting upon the blood-vessels: (1) General arterio-sclerosis,
with or without renal disease; (3) all states of increased arterial tension
induced by the contraction of the smaller arteries under the influence of
certain toxic substances, which, as Bright suggested, " by affecting the
minute capillary circulation, render greater action necessary to send the blood
through the distant subdivisions of the vascular system"; (3) prolonged hius-
cular exertion, which enormously increases the blood-pressure in the arteries;
(4) narrowing of the aorta, as in the congenital stenosis.
Hypeetroppiy of the right ventricle is met with under the following
conditions —
(1) Lesions of the mitral valve, either incompetence or stenosis, which
act by increasing the resistance in the pulmonary vessels. (3) Pulmonary
lesions, obliteration of any number of blood-vessels within the lungs, such
as occurs in emphysema or cirrhosis, is followed by hypertrophy of the right
ventricle. (3) Valvular lesions on the right side occasionally cause hyper-
trophy in the adult, not infrequently in the foetus. (4) Chronic valvular dis-
ease of the left heart and pericardial adhesions are sooner or later associated
with hypertrophy of the right ventricle.
In the auricles simple hypertrophy is never seen; there is always dilata-
tion with hypertrophy. In the left auricle the condition develops in lesions
at the mitral orifice, particularly stenosis. The right auricle hypertrophies
when there is greatly increased blood-pressure in the lesser circulation, whether
due to mitral stenosis or pulmonary lesions. ISTarrowing of the tricuspid orifice
is a less frequent cause.
2. Lesions due to Disease of the Coronary Arteries.
A knowledge of the changes produced in the myocardium by disease of the
coronary vessels gives a key to the understanding of many problems in cardiac
pathology. The terminal branches of the coronary vessels are end-arteries;
that is, the communication between neighboring branches is through capillaries
only. J. H. Pratt has shown that the vessels of Thebesius, which open from
the ventricles and auricles into a system of fine branches and thus communi-
cate with the cardiac capillaries and coronary veins, may be capable of feeding
the myocardium sufficiently to keep it alive even when the coronary arteries
are occluded. The blocking of one of these vessels by a thrombus or an
embolus leads usually to a condition which is known as —
(a) Anaemic necrosis, or white infarct. When this does not occur the
reason may be sought in (1) the existence of abnormal anastomoses, which
by their presence take the coronary system out of the group of end-arteries;
or (3) the vicarious flow through the vessels of Thebesius and the coronary
veins. The condition is most commonly seen in the left ventricle and in the
septum, in the territory of distribution of the anterior coronary artery. The
affected area has a yellowish-white color, sometimes a turbid, parboiled aspect,
at other times a grayish-red tint. It ma}^ be somewhat wedge-shaped, more
often it is irregular in contour and projects above the surface. Microscopically
the changes are very characteristic. The nuclei either disappear from the
muscle fibres or they undergo fragmentation. Leucocytes wander in from
the surrounding tissue, and these may suffer disintegration. At a later stage
a new growth of fibrous tissue is found in the periphery of the infarct which
824 DISEASES OF THE CIRCULATORY SYSTEM.
■ultimately may entirely replace the dead fibres. The fibres present a homo-
geneous, hyaline appearance. In some instances there is complete transforma-
tion, and even to the naked eye a firm white patch of hyaline degeneration
may appear in the centre of the area. Eupture of the heart may be asso-
ciated with angemic necrosis.
(&) The second important effect of coronar3^-artery disease upon the myo-
cardium is seen in the production of fibrous myocarditis. This may result
from the gradual transformation of areas of anaemic necrosis. More commonly
it is caused by the narrowing of a coronary branch in a process of obliterative
endarteritis. Where the process is gradual evidences of granulation tissue
are often wanting, and any distinction between the necrotic muscle fibres and
the new scar tissue is difficult to establish. J. B. MacCallum has shown that
the muscle fibres undergo a change the reverse of that of their normal develop-
ment and lose their fibril bundles preliminary to their complete replacement
by connective tissue. The sclerosis is most frequently seen at the apex of the
left ventricle and in the septum, but it may occur in any portion. In the
septum and walls there are often streaks and patches which are only seen
in carefully made serial sections. II}"pertrophy of the heart is commonly
associated with this degeneration. It is the invariable precursor of aneurism
of the heart.
(c) Sudden Death in Coronary Artery Disease. — Complete obliteration
of one coronary artery, if produced suddenly, is usually fatal. When in-
duced slowly, either by arterio-sclerosis at the orifice of the artery at the root of
the aorta or by an obliterating endarteritis in the course of the vessel, the circu-
lation may be carried on through the other vessel. Sudden death is not uncom-
mon, owing to thrombosis of a vessel which has become narrowed by sclerosis.
In medico-legal cases it is a point of primary importance to rememher that this
is one of the common causes of sudden death. This condition should be care-
fully sought for, inasmuch as it may be the sole lesion, except a general, some-
times slight arterio-sclerosis. In the most extreme grade one coronary artery
may be entirely blocked, with the production of extensive fibroid disease, and
a main branch of the other also may be occluded. A large, powerfully built
imbecile, aged thirty-five, at the Elw^m Institution, Pennsylvania, who had for
years enjoyed doing the heavy work about the place, died suddenly, without
any preliminaiy sj^mptoms. The heart weighed over 600 grammes; the an-
terior coronary artery was practically occluded by obliterating endarteritis,
and of the posterior artery one main branch was blocked.
{d) Septic Infarcts. — In pyemia the smaller branches of the coronary
. arteries may be blocked with emboli which give rise to infectious or septic
infarcts in the myocardium in the form of abscesses, varying in size from a
pea to a pin's head. These may not cause any disturbance, but when large they
may perforate into the ventricle or into the pericardium, forming what has
been called acute ulcer of the heart.
3. Acute Inteestitial Mtocaeditis.
In some infectious diseases and in acute pericarditis the intermuscular con-
nective tissue may be swollen and infiltrated with small round cells and
leucoc}'i:es, the blood-vessels dilated, and the muscle fibres the seat of granular,
fatty, and hyaline degeneration. Occasionally, in pyaemia the infiltration with
DISEASES OF THE HEART. 825
pus-cells has been diffuse and confined chiefly to the interstitial tissue. Coun-
cilman has described this condition of the heart wall in gonorrhoea, and
succeeded in demonstrating the gonococcus in the diseased areas. The com-
monest examples are found in diphtheria, typhoid fever, and acute endo-
carditis, as shown by the studies of Eomberg, The foci may be the starting-
points of patches of fibrous myocarditis.
4. Feagmentation" and Segmentation.
This condition was described by Renaut and Landouzy in 1877, and has
been carefully studied by different pathologists. Two forms are met with:
1. Segmentation. The muscle fibres have separated at the cement line.
2. Fragmentation. The fracture has been across the fibre itself, and perhaps
at the level of the nucleus. Longitudinal division is unusual. Although the
condition doubtless arises in some instances during the death agony, as in
cases of sudden death by violence, in others it would seem to have clinical and
pathological significance. It is found associated with other lesions, fibrous
myocarditis, infarction, and fatty degeneration. J. B. MacCallum distin-
guishes a simple from a degenerative fragmentation. The first takes place
in the normal fibre, which, however, shows irregular extensions and contrac-
tions. The second succeeds degeneration in the fibre. Hearts the seat of
marked fragmentation are lax, easily torn, the muscle fibres widely separated,
and often pale and cloudy.
5. Parenchymatous Degeneration.
This is usually met with in fevers, or in connection with endocarditis or
pericarditis, and in infections and intoxications generally. It is characterized
by a pale, turbid state of the cardiac muscle, which is general, not localized.
Turbidity and softness are the special features. It is the softened heart of
Laennec and Louis. Stokes speaks of an instance in which " so great was the
softening of the organ that when the heart was grasped by the great vessels and
held with the apex pointing upward, it fell down over the hand, covering it like
a cap of a large mushroom.''
Histologically, there is a degeneration of the muscle fibres, which are
infiltrated to a various extent with granules which resist the action of ether,
but are dissolved in acetic acid. Sometimes this granular change in the fibres
is extreme, and no trace of the striae can be detected. It is probably the effect
of a toxic agent, and is seen in its most exquisite form in the lumbar muscles
in cases of toxic hsemoglobinuria in the horse. It is met with in cases of
typhoid, typhus, small-pox, and other infectious diseases, particularly when
the course is protracted. There is no definite relation between it and the high
temperature.
6. Fatty Heart.
Under this term are embraced fatty degeneration and fatty overgrowth.
(a) Fatty degeneration is a very common condition, and mild grades are
met with in many diseases. It is found in the failing nutrition of old age,
of wasting diseases, and of cachectic states; in prolonged infectious fevers, in
which it may follow or accompany the parenchymatous change. In pernicious
anaemia and in phosphorus poisoning the most extreme degrees are seen. Peri-
54
826 DISEASES OF THE CIRCULATORY SYSTEM.
carditis is usually associated with fatty or parenchymatous changes in the
superficial layers of the myocardium. Disease of the coronary arteries is a
much more common cause of fibroid degeneration than of fatty heart. Lastly,
in the hypertrophied ventricular wall in chronic heart-disease fatty change is
by no means infrequent. This degeneration may be limited to the heart or it
may be more or less general in the solid viscera. The diaphragm may also be
involved; even vrhen the other muscles show no special changes. There appears
to be a special proneness to fatty degeneration in the heart-muscle, which may
perhaps be connected with its incessant activity. So great is its need of an
abundant ox3"gen supply that it feels at once any deficiency, and is in conse-
quence the first muscle to show nutritional changes.
Anatomically the condition may be local or general. The left ventricle is
most frequently affected. If the process is advanced and general, the heart
looks large and is flabby and relaxed. It has a light yellowish-bro"v\ai tint,
or, as it is called, a faded-leaf color. Its consistence is reduced and the sub-
stance tears easily. In the left ventricle the papillary columns and the muscle
beneath the endocardium show a streaked or patchy appearance. Micro-
scopically, the fibres are seen to be occupied by minute globules distributed
in rows along the line of the primitive fibres (Welch). In advanced grades
the fibres seem completely occupied by the minute globules.
(&) Fatty Overgrowth.- — This is usually a simple excess of the normal
subpericardial fat, to which the term cor adiposum was given by the older
writers. In pronounced instances the fat infiltrates between the muscular sub-
stance and, separating the strands, may reach even to the endocardium. In
corpulent persons there is always much pericardial fat. It forms part of the
general obesit}^, and occasionally leads to dangerous or even fatal impairment
of the contractile power of the heart. Of 123 cases analyzed by Forchheimer
there were 88 males and 34 females. Over 80 per cent occurred between the
fortieth and seventieth years.
The entire heart may be enveloped in a thick sheeting of fat through
which not a trace of muscle substance can be seen. On section, the fat infil-
trates the muscle, separating the fibres, and in extreme cases — ^particularly
in the right ventricle — reaches the endocardium. In some places there may
be even complete substitution of fat for the muscle substance. In rare in-
stances the fat may be in the papillary muscles. The heart is usually much
relaxed and the chambers are dilated. Microscopically the muscle fibres may
show, in addition to the atrophy, marked fatty degeneration.
7. Other Degenerations of the Myocardium.
(a) Brown Atrophy. — This is a common change in the heart-muscle, par-
ticularly in chronic valvular lesions and in the senile heart. When advanced,
the color of the muscles is a dark red-brown, and the consistence is usually
increased. The fibres present an accumulation of yellow-brown pigment chiefly
about the nuclei. The cement substance is often unusually distinct, but seems
more fragile than in healthy muscle.
(b) Amyloid degeneration of the heart is occasionally seen. It occurs in
the intermuscular connective tissue and in the blood-vessels, not in the fibres.
(c) The hyaline transformation of Zenker is sometimes met with in pro-
■ DISEASES OF THE HEART. 827
longed fevers. The affected fibres are swollen, homogeneous, translucent, and
the striae are very faint or entirely absent.
(d) Calcareous degeneration may occur in the myocardium, and the muscle
fibres may be infiltrated and yet retain their appearance as figured and de-
scribed by Coats in his Text-book of Pathology.
Symptoms of Myocardial Disease.
With a " weak heart," without valvular disease or renal changes, the patient
has shortness of breath on exertion, a feeble, irregular pulse, and there are signs
of cardiac dilatation — feeble impulse, increased area of flatness, and usually
a gallop rhythm, sometimes a soft apex-systolic murmur. The myocardial
lesion is not always proportionate to the intensity of the symptoms. A patient
may present enfeebled, irregular action and signs of dilatation — shortness of
breath, oedema, and the general symptoms believed to be characteristic of
cases of fibroid and fatty heart — and the post mortem show little or no
change in the myocardium.
Cardiosclerosis or fibroid heart is in some cases characterized by a feeble,
irregular, slow pulse, with dyspnoea on exertion and occasional attacks of
angina. Irregularity is present in many, but not in all cases. The pulse
may be very slow, even 30 or 40 per minute, and the features those of Stokes-
Adams disease. A man with advanced fibroid myocarditis may die suddenly
while at work, without having ever complained of heart trouble. Ultimately
the cases come under observation with the symptoms of cardiac insufficiency.
The arrhythmia, which may have been present, becomes aggravated and,
according to Kiegel, may not only precede, but also persist after the cardiac
insufficiency has passed away.
Fatty degeneration of the heart presents the same difficulties. Extreme
fatty changes, as in pernicious anaemia, may be present with a full pulse and
regularly acting heart. The fat does not appear to interfere seriously with the
function of the organ. The truth is, it may be present in an extreme grade
without producing symptoms, so long as great dilatation of the chambers does
not occur. The cardiac irregularity, the dyspnoea, palpitation, and small pulse
are in reality not symptoms of the fatty degeneration, but of dilatation which
has supervened. The fatty arcus senilis is of no moment in the diagnosis of
fatty heart. The heart-sounds may be weak and the action irregular.
When dilatation occurs, there is gallop rhythm, shortening of the long
pause, and a systolic murmur at the apex. Shortness of breath on exertion
is an early feature in many cases, and anginal attacks may occur. There is
sometimes a tendency to syncope, and in both fibroid and fatty heart there
are attacks in which the patient feels cold and dej^ressed and the pulse sinks
to 40 or 30, or even, as in one case which I saw, to 36. The patient may
wake from sleep in the early morning with an attack of severe cardiac asthma.
These " spells " may be associated with nausea and may alternate with others
in which there are anginal symptoms. These are the cases, too, in which for
weeks there may be mental symptoms. The patient has delusions and may
even become maniacal. Toward the close, the type of breathing known as
Cheyne-Stokes may occur. It was described in the following terms by John
Cheyne, speaking of a case of fatty heart (Dublin Hospital Eeports, vol. ii,
p. 231, 1818) : " For several days his breathing was irregular; it would entirely
828 DISEASES OF THE CIRCULATORY SYSTEM.
cease for a quarter of a minute, then it would become perceptible, though very
low, then by degrees it became heaving and quick, and then it would gradually
cease again : this revolution in the state of his breathing lasted about a minute,
during which there were about thirty acts of respiration/' It is seen much
more frequently in arterio-sclerosis and ursemic states than in fatty heart.
Fatty overgrowth of the heart is a condition certain to exist in very obese
persons. It produces no sj^mptoms until the muscular fibre is so weakened
that dilatation occurs. These patients may for years present a feeble but
regular pulse; the heart-sounds are weak and muffled, and a murmur may be
heard at the apex. Attacks of cardiac asthma are not uncommon, and the
patient may suffer from bronchitis. Dizziness and pseudo-apoplectic seizures
may occur. Sudden death may result from syncope or from rupture of the
heart. The physical examination is often difficult because of the great increase
in the fat, and it may be impossible to define the area of dulness.
For clinical purposes we may group the cases of myocardial disease as
follows :
(1) Those in which sudden death occurs with or without previous indi-
cations of heart-trouble. Sclerosis of the coronary arteries exists — in some
instances with recent thrombus and white infarcts ; in others, extensive fibroid
disease; in others again, fatty degeneration. Many patients never complain
of cardiac distress, but, as in the case of Chalmers, the celebrated Scottish
divine, enjoy unusual vigor of mind and body.
(2) Cases in which there are cardiac arrhythmia, shortness of breath on
exertion, attacks of cardiac asthma, sometimes anginal attacks, collapse symp-
toms with sweats and extremely slow pulse, and occasionally marked mental
symptoms.
(3) Cases with general arterio-sclerosis and hypertrophy and dilatation
of the heart. They are robust men of middle age who have worked hard
and lived carelessly. Dyspnoea, cough, and swelling of the feet are the early
symptoms, and the patient comes under observation either with a gallop
rhythm, embryocardia, or an irregular heart with an apex systolic murmur
of mitral insufficiency. Eecovery from the first or second attack is the rule.
It is one of the most common forms of heart-disease.
Prognosis.
The outlook in affections of the myocardium is extremely grave. Patients
recover, however, in a surprising way from the most serious attacks, particu-
larly those of the third group.
Treatment.
Many cases never come under treatment; the first are the final symptoms.
Cases with signs of well-marked cardiac insufficiency, as manifested by
dyspnoea, weak, irregular, rapid heart, and oedema, may be treated on the
plan laid down for the treatment of broken compensation in valvular disease.
Digitalis may be given even if fatty degeneration is suspected, and is often
very beneficial.
Much more difficult is the management of those cases in which there is
marked cardiac arrhythmia, with a feeble, irregular, very slow pulse, and syn-
cope or angina. Dropsy is not, as a rule, present; the heart-sounds may be
DISEASES OF THE HEART. 829
perfectly clear, and there are no signs of dilatation. Digitalis, under these
circumstances, is not advisable, particularly when the pulse is infrequent.
Complete rest in bed, a carefully regulated diet, and the use of the aromatic
spirits of ammonia, sulphuric ether, and stimulants are indicated. For the
restlessness and distressing feelings of anxiety morphia is invaluable. From
an eightieth to a sixtieth of a grain of strychnia may be given three times
a day. If the pulse is hard and firm and the blood pressure high the sodium
nitrites or nitroglycerin should be given freely.
In certain cases of weak heart, particularly when it is due to fatty over-
growth, the plans recommended by Oertel and by Schott are advantageous.
They are invaluable methods in those forms of heart-weakness due to intem-
perance in eating and drinking and defective bodily exercise. The Oertel
plan consists of three parts: First, the reduction in the amount of liquid.
This is an important factor in reducing the fat in these patients. It also
slightly increases the density of the blood. Oertel allows daily about 36 ounces
of liquid, which includes the amount taken with the solid food. Free perspira-
tion is promoted by bathing (if advisable, the Turkish bath), or even by the
use of pilocarpine.
The second important point in his treatment is the diet, which should
consist largely of proteids.
Morning. — Cup of coffee or tea, with a little milk, about 6 ounces alto-
gether. Bread, 3 ounces.
Noon. — Three to 4 ounces of soup, 7 to 8 ounces of roast beef, veal, game,
or poultry, salad or a light vegetable, a little fish ; 1 ounce of bread or farina-
ceous pudding; 3 to 6 ounces of fruit for dessert. No liquids at this meal, as
a rule, but in hot weather 6 ounces of light wine may be taken.
Afternoon. — Six ounces of coffee or tea, with as much water. As an
indulgence an ounce of bread.
Evening. — One or 2 soft-boiled eggs, an ounce of bread, perhaps a small
slice of cheese, salad, and fruit; 6 to 8 ounces of wine with 4 or 5 ounces of
water (Yeo).
The most important element of all is graduated exercise, not on the level,
but up hills of various grades. The distance walked each day is marked off
and is gradually lengthened. In this way the heart is systematically exer-
cised and strengthened.
The Schott Treatment. — This consists in a combination of baths with
exercises at liauheim. The water has a temperature of from 83°-95° F.,
and is very richly charged with COg. The good effects of the bath are claimed
by Schott to come from a cutaneous excitation, induced by the mineral and
gaseous constituents of the bath, and a stimulation of the sensory nerves.
There is no question that the bath, in suitable cases, will alter the position
of the apex beat, and that it lessens the area of cardiac dulness; this means
that it diminishes the dilatation of the heart. Artificial baths are used, con-
sisting of forty gallons of water, with various strengths of sodium chloride and
calcium chloride. The exercises, resistance gymnastics, consist in slow move-
ments executed by the patient and resisted by the operator. The best cases for
the ISTauheim treatment are those with myocardial weakness from whatever
cause. For valvular heart diseases in the stage of broken compensation with
dropsy, etc., it is not so suitable. The neurotic heart is often much benefited.
830 DISEASES OF THE CIRCULATORY SYSTEM.
IV. ANEURISM OF THE HEART.
(a) Aneurism of a valve results from acute endocarditis, which produces
softening or erosion and may lead either to perforation of the segment or to
gradual dilatation of a limited area under the influence of the blood-pressure.
The aneurisms are usually spheroidal and project from the ventricular face
of a sigmoid valve. They are much less common on the mitral segments.
They frequently rupture and produce extensive destruction and incompetency
of the valves.
(&) Aneurism of the walls results from the weakening induced by chronic
myocarditis, or occasionally it follo^ys acute mural endocarditis, which more
commonly, however, leads to perforation. It has followed a stab-wound, a
gumma of the ventricle, and, according to some authors, pericardial adhesions.
The left ventricle near the apex is usually the seat, this being the situation
in which fibrous degeneration is most common. Fifty-nine of the 60 cases
collected by Legg were situated here. In the early stages the anterior wall
of the ventricle, near the septum, sometimes even the septum itself, is slightly
dilated, the endocardium opaque, and the muscular tissue sclerotic. In a
more advanced stage the dilatation is pronounced and layers of thrombi occupy
the sac. Ultimately a large rounded tumor may project from the ventricle and
may attain a size equal to that of the heart. Occasionally the aneurism is
sacculated and communicates with the ventricle through a very small orifice.
The sac may be double, as in the cases of Janeway and Sailer. In the museum
of Guy's Hospital there is a specimen showing the wall of the ventricle cov-
ered with aneurismal bulgings. Eupture occurred in 7 of the 90 cases col-
lected by Legg.
The symptoms produced by aneurism of the heart are indefinite. Occa-
sionally there is marked bulging in the apex region and the tumor may
perforate the chest wall. In mitral stenosis the right ventricle may bulge
and produce a visible pulsating tumor below the left costal border, which I
have known to be mistaken for cardiac aneurism. When the sac is large and
produces pressure upon the heart itself, there may be a marked disproportion
between the strong cardiac impulse and the feeble pulsation in the peripheral
arteries.
V. RUPTURE OF THE HEART.
This rare event is usually associated with fatty infiltration or degenera-
tion of the heart-muscles. In some instances, acute softening in consequence
of embolism of a branch of the coronary artery, suppurative myocarditis, or
a gummatous growth has been the cause. Of 100 cases collected by Quain,
fatty degeneration was noted in 77. Two-thirds of the patients were over
sixty years of age. It may occur in infants. Schaps reports a case in an
infant of four months associated with an embolic infarct of the left ventricle.
Harvey, in his second letter to Eiolan (1649), described the case of Sir Robert
Darcy, who had distressing pain in the chest and s3aicopal attacks with suffoca-
tion, and finally cachexia and dropsy. Death occurred in one of the parox-
ysms. The wall of the left ventricle of the heart was ruptured, " having a
DISEASES OF THE HEART. 831
rent in it of size sufficient to admit any of my fingers, although the wall itself
appeared sufficiently thick and strong."
The rent may occur in any of the chambers, but is found most frequently
in the left ventricle on the anterior wall, not far from the septum. The
accident usually takes place during exertion. There may be no preliminary
symptoms, but without any warning the patient may fall and die in a few
moments. Sudden death occurred in 71 per cent of Quain^s cases. In other
instances there may be in the cardiac region a sense of anguish and suffoca-
tion, and life may be prolonged for several hours. In a Montreal case, which
I examined, the patient walked up a steep hill after the onset of the symptoms,
and lived for thirteen hours. A case is on record in which the patient lived
for eleven days.
VI. NEW GROWTHS AND PARASITES.
Tubercle and syphilis have already been considered. Primary cancer or
sarcoma is extremely rare. Secondary tumors may be single or multiple, and
are usually unattended with symptoms, even when the disease is most exten-
sive. In one case I found in the wall of the right ventricle a mass which
involved the anterior segment of the tricuspid valve and partly blocked the
orifice. The surface was eroded and there were numerous cancerous emboli
in the pulmonary artery. In another instance the heart was greatly enlarged,
owing to the presence of innumerable masses of colloid cancer the size of
cherries. The mediastinal sarcoma may penetrate the heart, though it is
remarkable how extensive the disease of the mediastinal glands may be with-
out involvement of the heart or vessels.
Cysts in the heart are rare. They are found in different parts, and are
filled either with a brownish or a clear fluid. Blood-cysts occasionally occur.
The parasites have been discussed under the appropriate section, but it
may be mentioned here that both the cysticerus cellulosce and the echinococcus
cysts occur occasionally.
VII. WOUNDS AND FOREIGN BODIES.
Wounds of the heart may be caused by external injuries, as stabs and
bullet wounds, by foreign bodies passing from the gullet or oesophagus, or by
puncture for therapeutic purposes.
(1) Bullet wounds of the heart are common. Eecovery may take place,
and bullets have been found encysted in the organ. Stab wounds are still
more common. A medical student, while on a spree, passed a pin into his
heart. The pericardium was opened, and the head of the pin was found out-
side of the right ventricle. It was grasped and an attempt made to remove
it, but it was withdrawn into the heart and, it is said, caused the patient no
further trouble (Moxon). In recent stab wounds it is a good practice to
expose the heart and attempt to suture the wound. Sherman has collected 34
operations performed in the six years ending 1901, of which 13 recovered. In
a case of stab-wound Pagenstecher tied the left coronary artery, which had
been divided.
(3) Hysterical girls sometimes swallow pins and needles, which, passing
832 DISEASES OF THE CIRCULATORY SYSTEM.
through the oesophagus and stomach, are found in various parts of the body.
A remarkable case is reported by Allen J. Smith of a girl from whom several
dozen needles and pins were removed, chiefly from subcutaneous abscesses.
Several years later she developed s}Tnptoms of chronic heart-disease. At the
post mortem needles were found in the tissues of the adherent pericardium, and
between thirty and forty were embedded in the thickened pleural membranes
of the left side.
(3) Puncture of the heart (cardiocentesis) has been recommended as a
therapeutic procedure, as in chloroform narcosis, and experimental evidence
has been brought forward by B. A. Watson in favor of the operation. He
advises abstraction of blood in combination with the puncture — cardiocentesis.
The proceeding is not without risk. Haemorrhage may take place from the
puncture, though it is not often extensive. Sloane has recently urged its use
in all cases of asphyxia and in suffocation by dro^vning and from coal-gas.
The successful case which he reports illustrates forcibly its stimulating action.
VIII. FUNCTIONAL AFFECTIONS OF THE HEART.
I. Palpitation.
In health we are unconscious of the action of the heart. One of the first
indications of debility or overwork is the consciousness of the cardiac pulsa-
tions, which may, however, be perfectly regular and orderly. This is not
palpitation. The term is properly limited to irregular or forcible action of the
heart perceptible to the individual. The condition of extra-systole described
in the next section is present in many cases.
Etiology. — The expression " perceptible to the individual " covers the
essential element in palpitation of the heart. The most extreme disturbance
of rhythm, a condition even of what is termed delirium cordis, may be unat-
tended with subjective sensations of distress, and there may be no conscious-
ness of disturbed action. On the other hand, there are cases in which com-
plaint is made of the most distressing palpitation and sensations of throbbing,
in which the physical examination reveals a regularly acting heart, the sensa-
tions being entirel}'' subjective. We meet with this symptom in a large group
of cases in which there is increased excitability of the nervous system. Palpi-
tation may be a marked feature at the time of puberty, at the climacteric, and
occasionally during menstruation. It is a very common symptom in hysteria
and neurasthenia, particularly in the form of the latter which is associated
with dyspepsia. Emotions, such as fright, are common causes of palpitation.
It may occur as a sequence of the acute fevers. Females are more liable to the
affection than males.
In a second group the palpitation results from the action upon the heart
of certain substances, such as tobacco, coffee, tea, and alcohol. And, lastly,
palpitation may be associated with organic disease of the heart, either of the
myocardium or of the valves. As a rule, however, it is a purely nervous phe-
nomenon— seldom associated with organic disease — in which the most violent
action and the most extreme irregularity may exist without that subjective
element of consciousness of the disturbance which constitutes the essential
feature of palpitation.
DISEASES OF THE HEART. 833
The irritable heart described by Da Costa, which was so common among
the young soldiers during the civil war, is a neurosis of this kind. The chief
symptoms were palpitation with great frequency of the pulse on exertion, a
variable amount of cardiac pain, and dyspnoea. The factors at work in pro-
ducing this condition appeared to be the mental excitement, the unwonted
muscular exertion associated with the drill, and diarrhosa. The condition is
not infrequent in civil life among young men, and when persistent it may
lead to hypertrophy of the heart.
Symptoms. — In the mildest form, such as occurs during a dyspeptic attack,
there is slight fluttering of the heart and a sense of what patients sometimes
call "goneness." In more severe attacks the heart beats violently, its pulsa-
tions against the chest wall are visible, the rapidity of the action is much
increased, the arteries throb forcibly, and there is a sense of great distress. In
some instances the heart's action is not at all quickened. The most striking
cases are in neurasthenic women, in whom the mere entrance of a person into
the room may cause the most violent action of the heart and throbbing of the
peripheral arteries. The pulse may be rapidly increased until it reaches 150
or 160. A diffuse flushing of the skin may appear at the same time. After
such attacks, there may be the passage of a large quantity of pale urine. In
many cases of palpitation, particularly in young men, the condition is at once
relieved by exertion. A patient with extreme irregularity of the heart may,
after walking quickly 100 yards or running upstairs, return with the pulse
perfectly regular. This is not infrequently seen, too, in the irregular action of
the heart in mitral valve disease.
The physical examination of the heart is usually negative. The sounds,
the shock of which may be very palpable, are on auscultation clear, ringing,
and metallic, but not associated with murmurs. The second sound at the
base may be greatly accentuated. A murmur may sometimes be heard over
the pulmonary artery or even at the apex in cases of rapid action in neuras-
thenia or in severe ansemia. The attacks may be transient, lasting only for a
few minutes, or may persist for an hour or more. In some instances any
attempt at exertion renews the attack.
The prognosis is usually good, though it may be extremely difficult to
remove the conditions underlying the palpitation.
II. Arrhythmia.
The work of Gaskell and of Engelmann on the function of the heart-
muscle, and the clinical studies of James Mackenzie, Wenckebach, and others,
have modified the older views of the neurogenic cardiac mechanism with its
musculo-motor nerve centre upon which the higher centres played through
the vagi and the sympathetic nerves. The source of the action of the heart is
now placed in the muscle itself — myogenic — and Gaskell describes as its func-
tions rhythmicity, excitability, contractility, conductivity, and tonicity ; " that
is to say, the muscular fibres of the heart possess the power of rhythmically
creating a stimulus, of being able to receive a stimulus, of responding to a
stimulus by contracting, of conveying the stimulus from muscle fibre to muscle
fibre, and of maintaining a certain ill-defined condition called tone." Wencke-
bach and James Mackenzie have studied the disturbances of these functions
of the heart clinically, and have endeavored to classify them in harmony with
834 DISEASES OF THE CIRCULATORY SYSTEM.
the myogenic theory. I am indebted to Joseph Erlanger, of the Johns Hop-
kins Physiological Laboratory^ for the following classification based on that of
Wenckebach :
I. Arrhythmia resulting from decreased conductivity in the auriculo-
ventricular junction — heart-hlock. Characteristics : Auricular rhythm perfect,
rate normal or accelerated ; ventricular rhythm may or may not be perfect ; if
perfect its rate will be one-half of that of the auricles, or less ; if not perfect the
irregularities will bear some direct relation to the contractions of the auricles.
A. Partial heart-block: (1) Occasional ventricular silence; (2) regularly
recurring ventricular silence, either one ventricular beat missed in 7, 6, 5, 4,
etc., auricular beats, or a 2 : 1, 3 : 1, 4 : 1 rhythm, or either of these alternating,
B. Complete heart-block: Auricular and ventricular rhythms perfect but
independent,
XJ, Paroxysmal bradycardia ( Stokes- Adams disease) affecting the ventricu-
lar rate alone.
II. Arrhythmia resulting from increased irritability of the heart.
A. Ventricular extra-systoles, characterized by an early systole, which is
associated with the phenomena of a retrograde impulse. There may be one
or more extra-systoles following a normal systole; when regularly recurring,
one or more extra-systoles after 5, 4, 3, 2, or 1 normal systoles, the last giving
the bigeminal or trigeminal pulse, or there may be irregularly recurring extra-
systoles causing delirium cordis.
B. Auricular extra-systoles.
III. Arrhythmia resulting from the influence of extrinsic nerves upon the
heart-rate. (1) Vagus effects. (2) Accelerator effects,
IV. Arrhythmia resulting from disturbed diastolic filling of the heart.
A. Disturbed filling resulting from violent respiratory movements: may
give the paradoxical pulse.
B. Disturbed filling from adherent pericardium or mediastinal tumor : may
give the paradoxical pulse.
C. Associated respiratory and cardiac rhythm. Alternating pulse ( ?).
The senior student is referred to the work of Wenckebach, translated by
Thomas Snowball (1904), and to the writings of James Mackenzie. I can
here only refer to the more common and important disturbances of rhythm.
Intermittency. Extra-systoles. — The commonest type of arrhythmia is that
now known as the extra-systole, to explain which it must be remembered that
to a stimulus strong enough to set up a contraction the heart answers with all
the contractility of which it is capable at the moment (Bowditch's law of maxi-
mal contraction). A second property of the heart-muscle is that it possesses
a " refractory phase " in which normally it is not excitable, or answers only
to very strong stimuli. During this refractory stage, beginning shortly before
the systole and continuing a short time after it, the heart is inexcitable.
When not refractory it may again contract during this phase and produce an
extra-systole, which is followed by a long pause. Engelmann explains this
long pause as follows : " In consequence of the extra-systole the ventricle is still
in the refractory stage when the next physiological stimulus reaches it. This
stimulus therefore has no effect, no contraction takes place, and it is not till
the next stimulus after it that a contraction can again be produced. Thus
the normal systole that would follow the extra-systole is missed ; then the first
DISEASES OF THE HEART. 835
systole that comes after the compensatory pause occurs exactly at the moment
at which it would have occurred had no extra-systole preceded it" (Wencke-
bach). The irregularity, inequality, and intermission of the pulse as met
with in every-day clinical experience is largely due to the occurrence of these
extra-systoles, which may present all sorts of combinations and groupings,
bigeminal, trigeminal, etc., depending upon whether the extra pulse-beats are
perceptible or not. And yet in spite of this most extreme irregularity there
may be no actual pathological change, and so far as the maintenance of the
circulation is concerned the heart may be acting in a most satisfactory man-
ner. Patients may feel the extra-systole as a definite thud, and the compen-
satory pause is perceptible, but very often there are no subjective sensations.
Extra-systoles occur at all ages and under the most varied conditions in
health and disease. Mackenzie recognizes a youthful and an adult type of
arrhythmia, in which the latter is due chiefly to the presence of the systoles.
There are several classes of cases. The arrhythmia may be a life-long condi-
tion. Without any recognizable disease, without any impairment of the
action of the heart, there is permanent irregularity. This may be a peculiarity
of the heart-muscle of the individual, who has extra-systole for the same
reason — physiological but not well understood — as the dog and horse, in which
animals this phenomenon is common. The late Chancellor Ferrier, of McGill
University, who died at the age of eighty-seven, had an extremely irregular
heart action for the last fifty years of his life. I know several men who have
had for many years irregularity without the slightest discomfort. In debili-
tated and neurasthenic persons there may be an irritable weakness of the heart
associated with extra- systole, and palpitation of a most distressing character.
In a second group toxic agents, as tobacco, tea, coffee, or the poisons of the in-
fectious diseases or those originating in the intestines or metabolic poisons,
cause arrhythmia. Even reflexly, as in flatulent dyspepsia, extra-systoles may
arise. Thirdly, a high blood pressure can set up extra-systoles ; also change in
posture. And lastly, organic disease of the heart itself, " dilatation, inflamma-
tion, poor blood supply to the muscle, overexertion can all supply stimuli to
set up extra-systoles either directly or reflexly" (Wenckebach). Too much
stress should not be laid upon arrhythmia per se in the absence of organic
disease.
III. Eapid Heart — Tachycardia.
The rapid action may bp perfectly natural. There are individuals whose
normal heart action is at 100 or even more per minute. Emotional causes,
violent exercise, and fevers all produce great increase in the rapidity of the
heart's action. The extremely rapid action which follows fright may persist
for days, or even weeks. Traube reports an instance in which, after violent
exercise, the rapidity of the heart continued. Cases are not uncommon at the
menopause.
There are cases again in which the condition can hardly be termed a
neurosis, since it depends upon definite changes in the pneumogastrics or
in the medulla. Cases have been reported in which tumor or clot in or about
the medulla or pressure upon the vagi has been associated with heart hurry.
Some of the cases of frequent action of the heart in women have been thought
to be due to reflex irritation from ovarian or uterine disease.
836 DISEASES OF THE CIRCULATORY SYSTEM.
Paroxysmal tachycardia is a remarkable affection, characterized by spells
of heart hurry, during which the action is greatly increased, the pulse reach-
ing 200 and over. ■ The cases are not common. The attack may be quite short
and persist only for an hour or so. A patient at the Philadelphia Infirmary
for fsTervous Diseases was attacked every week or two; the pulse would rise
to 220 or 230, and there were such feelings of distress and uneasiness that
the patient always had to lie down. There may be, however, no subjective
disturbance, and in another case the patient was able to walk about during
the paroxysm and had no dyspnoea. One of the most remarkable cases is
reported by H. C. Wood. A physician in his eighty-seventh year had had
attacks at intervals from his thirty-seventh year. The onset was abrupt and
the pulse would rapidly rise to 200 a minute. For more than twenty years
the taking of ice-water or strong coffee would arrest the attacks. Bouveret
has analyzed a number of cases of this essential or idiopathic form; he finds
that a permanent cure is rare, and that the patients suffer for ten or more
years. Four instances terminated fatally from heart-failure. Martins looks
upon it as a sjonptom of an acute dilatation of the heart, appearing paroxys-
mally. One of the most remarkable features is the abruptness of onset and the
abruptness with which an attack may end. One of my cases had recurring
attacks lasting ten to thirty days, and the heart would suddenly " flop," as she
expressed it, the rate falling from 180 to 80 or 90 per minute.
IV. Slow Heaet — Beadycaedia — Heart-Block.
Slow action of the heart is sometimes normal and may be a family peculi-
arity. Xapoleon is stated to have had a pulse of only 40 per minute.
In any case of slow pulse it is important first to make sure that the
number of heart and arterial beats correspond. In many instances this is
not the case, and with a radial pulse at 40 the cardiac pulsations may be 80,
half the beats not reaching the wrist. The heart contractions, not the pulse
wave, should be taken into account.
(a) Physiological Bradycardia. — As age advances the pulse-rate becomes
slow. In the puerperal state the pulse may beat from 44 to 60 per minute, or
may even be as low as 34. It is seen in premature labor as well as at term.
The explanation of its occurrence at this period is not clear. Slowness of the
pulse is associated with hunger. Bradycardia depending on individual peculi-
arity is extremely rare.
(&) Pathological bradycardia^ which is met with under the following con-
ditions: (1) In convalescence from acute fevers. This is extremely common,
particularly after pneumonia, t3rphoid fever, acute rheumatism, and diph-
theria. It is most frequently seen in young persons and in cases which have
run a normal course. (2) In diseases of the digestive system, such els chronic
dyspepsia, ulcer or cancer of the stomach, and jaundice. (3) In diseases of
the respiratory system. Here it is by no means so common, but it is seen not
infrequently in emphysema. (4) In diseases of the circulatory system. Ex-
cluding all cases of irregularity of the heart, bradycardia is not common in
diseases of the valves. It is most frequently seen in fatty and fibroid changes
in the heart, but is not constant in them. (5) In diseases of the urinary
organs. It occurs occasionally in nephritis and may be a feature of uraemia.
DISEASES OF THE HEART. 837
(6) From the action of toxic agents. It occurs in uremia, poisoning by
lead, alcohol, and follows the use of tobacco, coffee, and digitalis. (7) In
constitutional disorders, such as anaemia, chlorosis, and diabetes. (8) In
diseases of the nervous system. Apoplexy, epilepsy, the cerebral tumors, affec-
tions of the medulla, and diseases and injuries of the cervical cord may be
associated with very slow pulse. In general paresis, mania, and melancholia
it is not infrequent. (9) It occurs occasionally in affections of the skin and
sexual organs, and in sunstroke, or in prolonged exhaustion from any cause.
V. Heart-block. Stokes-Adams Disease.
The impulse causing the heart to beat originates at the venous end of the
heart and is transmitted in such a way that the auricles contract first, the ven-
tricles a moment later, the impulse being propagated like a peristaltic wave
through the heart-walls. In passing from the auricle to the ventricle the
stimulus traverses a narrow band of muscle, the only demonstrable muscular
connection between the venous and arterial chambers. In the adult heart this
auriculo- ventricular bundle of His is 18 mm. long, 2.5 mm. broad, and 1.5
mm. thick ; it arises in the septum of the auricles below the foramen ovale and
passes downward and forward through the trigonum fibrosum of the auriculo-
ventricular junction, where it comes into close relation with the mesial leaflet of
the tricuspid valve. Passing along the upper edge of the muscular septum, just
where it joins with the posterior edge of the membranous septum, it radiates
from this point throughout the heart as the junctional system of Tawara. In
the dog destruction of the bundle prevents the passage from the auricle to the
ventricle of the impulse which normally causes the ventricles to contract. They
immediately assume a rate of beating which is very much slower than that of
the auricles and is totally independent, as they possess their own automatic
rhythmicity. Under ordinary circumstances this inherent rhythmicity can not
manifest itself because the much more rapidly beating venous end of the heart
sets the pace for the sluggish arterial end. But if the auricular impulse is
blocked, the ventricles released from the control of their normal pace maker
assume their own rate. This condition has been called complete heart-block.
By an ingenious contrivance Erlanger has been able in the dog to gradually
compress the auriculo-ventricular bundle and produce the various stages of
this condition, namely, one ventricular silence in 27 auricular beats, and
one ventricular silence with every other auricular beat, giving a 2 : 1 rhythm,
and proceeding to a 3:1 and a 4:1 rhythm. Finally, complete block
may result, in which no impulses pass from the auricles, but the ventri-
cles beat with their own inherent rate, which Erlanger estimates, from a
study of cases of heart-block in my wards, to be about 23 to 28 beats to the
minute in man. The explanation of the phenomenon is based upon one sug-
gested by Gaskell. The bundle of His, like all muscle tissue, becomes fatigued
when it is made to contract repeatedly. Under normal circumstances sufficient
time elapses between successive beats to permit the bundle to return to its
normal state, but when from injury or any cause the irritability of the bundle
is greatly reduced, it may not react to the auricular stimulus, which thus fails
to reach the ventricles. Occasionally while compressing the auriculo-ven-
tricular bundle in the dog, the ventricle alone may suddenly stop beating for
838 DISEASES OF THE CIRCULATORY SYSTEM.
as long as twenty seconds. Tlie explanation is here to be sought for the syn-
copal attacks in Stokes- Adams disease. In this condition the relaxed ventricles
are distended rhythmically by the beats of the auricles until the distension may
be extreme. The veins become engorged and pulsate synchronously with the
auricles. Each of the infrequent contractions of the ventricles relieves the
condition temporarily. When the heart-block is complete the vagi still exert
their normal control over the rate of the auricles, but they have lost almost
completely their influence over the ventricles, and in Stokes- Adams disease
we find the pulse-rate is little influenced by conditions wliich normally alter it,
as exercise, posture, etc.
Clinically Stokes- Adams disease presents these features: (a) slow pulse,
usually permanent, but sometimes paroxysmal, falling to 40, 20, or even 6
per minute; (h) cerebral attacks — vertigo of a transient character, syncope,
pseudo-apoplectiform attacks or epileptiform seizures; (c) visible auricular
impulses in the veins of the neck, as noted by Stokes — ^the beats varying
greatlj^, a 2 : 1 or 3 : 1 rhytlim is the most common. There are several groups
of cases. It is usually a senile manifestation associated with arterio-sclerosis.
The cases in young adults and middle-aged men are often myocardial and
of s}qDhilitic origin. There is a neurotic group in which all the features may
be present, and in which post mortem no lesions have been found (Edes and
Councilman). The outlook in this class of cases is good; in the others it is a
serious disease and usually fatal, though it may last for many years. The
cerebral attacks are due to ansmia of the brain or of the medulla in conse-
quence of the imperfect ventricular action. In one of my cases Baetjer could
see with the fluoroscope the more frequent contraction of the auricles.
Treatment of Palpitation and Arrliytlimia.
An important element in many cases is to get the patient's mind quieted,
and he can be assured that there is no actual danger. The mental element is
often very strong. In palpitation, before using medicines, it is well to try
the effect of Iwgienic measures. As a rule, moderate exercise may be taken
with advantage. Eegular hours should be kept, and at least ten hours out of
the twenty-four should be spent in the recumbent posture. A tepid bath may
be taken in the morning, or, if the patient is weakly and nervous, in the even-
ing, followed by a thorough rubbing. Hot baths and the Turkish bath should
be avoided. The dietetic management is most important. It is best to pro-
hibit absolutely alcohol, tea, and coffee. The diet should be light and the
patient should avoid taking large meals. Articles of food known to cause
fiatulencT should not be used. If a smoker, the patient should give up tobacco.
Sexual excitement is particularly pernicious, and the patient should be warned
specially on this point. For the distressing attacks of palpitation which occur
with neurasthenia, particularly in women, a rigid Weir Mitchell course is the
most satisfactory. It is in these cases that we find the most distressing throb-
bing in the abdomen, which is apt to come on after meals, and is very much
aggravated by flatulency. The cases of palpitation due to excesses or to errors
in diet and dyspepsia are readily remedied by hygienic measures.
A course of iron is often useful. Strychnia is particularly valuable, and
is perhaps best administered as the tincture of nux vomica in large doses.
DISEASES OF THE HEART. 839
Very little good is obtained from the smaller quantities. It should be given
freely, 20 minims three times a day.
If there is great rapidity of action, aconite may be tried or veratrum viride.
There are cases associated with sleeplessness and restlessness which are greatly
benefited by bromide of potassium. Digitalis is very rarely indicated, but in
obstinate cases it may be tried with the nux vomica.
Cases of heart hurry are often extremely obstinate, as may be judged from
the ease of the physician reported by H. C. Wood, in whom the condition per-
sisted in spite of all measures for fifty years. The bromides are sometimes
useful; the general condition of neurasthenia should be treated, and during
the paroxysm an ice-bag may be placed upon the heart, or Leiter's coil,
through which ice-water may be passed. Electricity, in the form of galvan-
ism, is sometimes serviceable, and for its mental effect the Franklinic current.
For the condition of slow pulse but little can be done. A great majority of
the eases are not dangerous.
IX. ANGINA PECTORIS.
Stenocardia, or the breast-pang, described by Heberden, is not an inde-
pendent affection, but a symptom associated with a number of morbid condi-
tions of the heart and vessels, more particularly with sclerosis of the root of
the aorta and changes in the coronary arteries. True angina is characterized
by paroxysms of agonizing pain in the region of the heart, extending into
the arms and neck. In violent attacks there is a sensation of impending
death.
Etiology. — It is a disease of adult life and occurs almost exclusively in
men. In Huchard's statistics of 237 cases only 42 were in women. In my
first series of 40 cases there was only one woman. It may occur through sev-
eral generations, as in the Arnold family. Gout and diabetes are important
factors. A number of cases of angina pectoris have followed influenza. At-
tacks are not infrequent in certain forms of heart-disease, particularly aortic
insufficiency and adherent pericardium. It is much less common in disease
of the mitral valve. Almost without exception the subjects of angina have
arterio-sclerosis, either general or localized at the root of the aorta, with
changes in the coronary arteries and in the myocardium. Severe attacks may
occur in the early period of the growth of aortic aneurism. In men under
thirty-five syphilitic aortitis is an important factor.
Phenomena of the Attack. — The exciting cause is in a majority of all
eases well defined. In only rare instances do the patients have attacks when
quiet. They come on during exertion most frequently, as in walking up hill
or doing something entailing sudden muscular effort; occasional^ even the
effort of dressing or of stooping to lace the shoes may bring on a paroxysm.
Mental emotion is a second very potent cause. John Hunter appreciated this
when he said that " his life was in the hands of any rascal who chose to annoy
and tease him." In his case a fatal attack occurred during a fit of anger.
A third, and in many instances the most important, factor is flatulent dis-
tention of the stomach. Another common exciting cause is cold; even the
chill of getting out of bed in the morning or on bathing may bring on a
paroxysm.
840 DISEASES OF THE CIRCULATORY SYSTEM.
Usually diiring exertion or intense mental emotion the patient is seized
with an agonizing pain in the region of the heart and a sense of constriction,
as if the heart had been seized in a vice. The pains radiate to the neck and
down the arm, and there may be numbness of the fingers or in the cardiac
region. The face is usually pallid and may assume an ashy-gray tint, and not
infrequently a profuse sweat breaks out over the surface. The paroxysm lasts
from several seconds to a minute or two, during which, in severe attacks, the
patient feels as if death were imminent. As pointed out by Latham, there
are two elements in it, the -psdn— dolor pectoris — and the indescribable feel-
ing of anguish and sense of imminent dissolution — an gar animi. There are
great restlessness and anxiety, and the patient may drop dead at the height
of the attack or faint and pass away in sjTicope. The condition of the heart
during the attack is variable; the pulsations may be uniform and regular.
The pulse tension, however, is usually increased, but it is surprising, even in
cases of extreme severity, how slightly the character of the pulse may be
altered. After the attack there ma}' be eructations, or the passage of a large
quantity of clear urine. The patient usually feels exhausted, and for a day
or two may be badly shaken ; in other instances in an hour or two the patient
feels himself again. "WTiile dyspnoea is not a constant feature, the paroxysm
is not infrequently associated with a form of asthma; there is wheezing in
the bronchial tubes, which may come on very rapidly, and the patient gets
short of breath. Many patients the subjects of angina die suddenly without
warning and not in a paroxysm. In other instances death follows in the first
well-marked paroxysm, as in the case of Thomas Arnold. In a third group
there are recurring attacks over long periods of years, as in John Hunter's
case; while in a fourth group of cases there are rapidly recurring attacks for
several days in succession, with progressive and increasing weakness of the
heart.
With reference to the radiation of pain in angina, the studies of Mac-
kenzie and of Head are of great interest. Head concludes that (1) in dis-
eases of the heart, and more particularly in aortic disease, the pain is referred
along the first, second, third, and fourth dorsal areas ; ( 2 ) in angina pectoris
the pain may be referred in addition along the fifth, sixth, and seventh, and
even the eighth and ninth dorsal areas, and is always accompanied by pain in
certain cervical areas. A remarkable fact is the early localization of the pain
in distant parts, not infrequently in the left arm; in one of my cases in the
left testis, and in another in the jaw.
Theories of . An^na Pectoris. — (1) That it is a neuralgia of the cardiac
nerves, but the agonizing cramp-like character of the pain, the suddenness of
the onset, and the associated features, are unlike any neuralgic aff'ection. The
pain, however, is undoubtedly in the cardiac plexus and radiates to adjacent
nerves. It is interesting lo note, in connection with the almost constant scle-
rosis of the coronary arteries in angina, that Thoma has found marked sclero-
sis of the temporal artery in migraine and Dana has met with local thickening
of the arteries in some cases of neuralgia. (2) Heberden believed that it
was a cramp of the heart-muscle itself. Cramp of certain muscular territories
would better explain the attack. (3) That it is due to the extreme tension of
the ventricular walls, in consequence of an acute dilatation associated, in the
majority of cases, with affection of the coronary arteries. Traube, who sup-
DISEASES OF THE HEART. 841
ported this view, held that the agonizing pain resulted from the great stretch-
ing and tension of the nerves in the muscular substance. A modified form
of this view is that there is a spasm of the coronary arteries with great increase
of the intracardiac pressure.
(4) The theory of Allan Burns, revived by Potain and others, that the
condition is one of transient ischasmia of the heart-muscle in consequence of
disease, or spasm, of the coronary arteries. The condition known as intermit-
tent claudication illustrates what may take place. In man (and in the horse),
in consequence of thrombosis of the abdominal aorta or iliacs, transient para-
plegia and spasm may follow exertion. The collateral circulation, ample
when the limbs are at rest, is insufficient after the muscles are actively used,
and a state of relative ischgemia is induced with loss of power, which disap-
pears in a short time. This " intermittent claudication " theory best explains
the angina paroxysm. A heart the coronary arteries of which are sclerotic
or calcified, is in an analogous state, and any extra exertion is likely to be fol-
lowed by a relative ischgemia and spasm. In Allan Burns's work on The Heart
(1809) the theory is discussed at length, but he does not think that spasm is
a necessary accompaniment of the ischsemia.
In fatal cases of angina the coronary arteries are almost invariably dis-
eased either in their main divisions, or there is chronic endarteritis with great
narrowing of the orifices at the root of the aorta. Experimentally, occlusion
of the coronary arteries produces slowing of the heart's action, gradual dila-
tation, and death within a very few minutes. Cohnheim has shown that in the
dog ligation of one of the large coronary branches produces within a minute
a condition of arrhythmia, and within two minutes the heart ceases in diastole.
These experiments, however, do not throw much light upon the etiology of
angina pectoris. Extreme sclerosis of the coronary arteries is common, and a
large majority of the cases present no symptoms of angina. Even in the cases
of sudden death due to blocking of an artery, particularly the anterior branch
of the coronary artery, there is usually no great pain either before or during
the attack.
Diagnosis. — There are many grades of true angina. A man may have
slight prascordial pain, a sense of distress and uneasiness, and radiation of
the pains to the arm and neck. Such attacks following slight exertion, an
indiscretion in diet, or a disturbing emotion, may alternate with attacks of
much greater severity, or they may occur in connection with a pulse of in-
creased tension and signs of general arterio-sclerosis. In the milder grades
the diagnosis can not rest upon the symptoms of the attack itsglf, since they
may be simulated by what is known as the neurotic or functional variety ; but
the diagnosis should be based upon the examination of the heart and arteries
and a careful consideration of the mode of onset and symptoms. The cases of
neurotic angina pectoris in women call for the greatest care in the diagnosis,
and attention to the points given in the table of Huchard will be of the great-
est aid. The existence of a marked increase in the blood-pressure is con-
firmatory evidence of organic disease.
Functional Angina Pectoris. — There are two main groups, the neu-
rotic and the toxic. The former embraces the hysterical and neurasthenic
cases, which are very common in women. Huchard has given an excellent
differential table between the two forms.
er symp-
Associated T\'itli nervous symp-
toms.
Agoniz-
Vaso-motor form common. Pain
compres-
less severe; sensation of distention.
^ttitude :
Pain lasts one or t'wo hours. Agi-
tation and activity.
coronary
Xeuralgia of nerves and cardio-
842 DISEASES OF THE CIRCULATORY SYSTEM.
TEUE A^;GINA. NEUEOTIC FORM.
Most common between the ages of At every age^ even six years,
forty and fifty years.
'Move common in men. Attacks More common in women. At-
hrought on by exertion. tacks spontaneous.
Attacks rarely periodical or noc- Often periodical and nocturnal.
turnal.
!N'ot associated with otl:
toms.
Vaso-motor form rare,
ing pain and sensation of
sion by a vice.
Pain of short duration.
silence, immobility.
Lesions : sclerosis of
artery. plexus.
Prognosis grave, often fatal. Xever fatal.
Arterial medication. Antineuralgic medication.
Notlmagel has described as vaso-motor angina a form in which the symp-
toms set in with coldness and nmnbness in the extremities, followed by great
precordial pain and feelings of faintness. Some have recognized also a reflex
variety.
Toxic Angina. — This embraces cases due to the abuse of tea, coffee, and
tobacco. There are three groups of cases of so-called tobacco heart : First, the
irritable heart of smokers, seen particularly in young lads, in which the sjnnp-
toms are palpitation, irregularit)^, and rapid action; secondly, heart pain of a
sharp, shooting character, which may be very severe ; and, thirdly, attacks of
such severitv' that they deserve the name of angina.
Prognosis. — Cardiac pain without evidence of arterio-sclerosis or valve-
disease is not of much moment. Angina in men is almost invariably associ-
ated with marked cardio-vascular lesions, in which the prognosis is alwa3's
grave. With judicious treatment the attacks, however, may be long deferred,
and a few instances recover completel3\ The prognosis is naturally more
serious with aortic insufficiency and advanced arterio-sclerosis. Patients who
have had well-marked attacks may live for many years, but much depends
upon the care with which they regulate their daily life.
Treatment. — Patients subject to this affection should live a quiet life,
avoiding particularly excitement and sudden muscular exertion. During the
attack nitrite of amyl should be inhaled, as advised by Lauder Brunton. From
3 to 5 drops may be placed upon cotton-wool in a tumbler or upon the hand-
kerchief. This is frequently of great service in the attack, relieving the ago-
nizing pain and distress. Subjects of the disease should carry the perles of
the nitrite of am}^ with them, and use them on the first indication of an
attack. In some instances the nitrite of amyl is quite powerless, though given
freely. If within a minute or two relief is not obtained in this way, chloro-
form should at once be given, A few inhalations act promptly and give great
DISEASES OF THE HEART. 843
relief. Should the pains continue, a hypodermic of morphia may be adminis-
tered. In severe and repeated paroxysms a patient may display remarkable
resistance to the action of this drug.
In the intervals, nitroglycerin may be given in full doses, as recom-
mended by Murrell, or the nitrite of sodium (Matthew Hay), The nitro-
glycerin should be used for a long time and in increasing doses, beginning
with 1 minim three times a day of the 1-per-cent solution, and increasing
the dose 1 minim every five or six days until the patient complains of flush-
ing or headache. The fluid extract of English hawthorn — Crategus oxycantlia
— has been strongly recommended by Jennings, Clements, and others.
Huchard recommends the iodides, believing that their prolonged use in-
fluences the arterio-sclerosis. Twenty grains three times a day may be given
for several years, omitting the medicine for about ten days in each month.
In some instances this treatment is most beneficial, particularly in middle-
aged men with a history of syphilis.
For the neurotic, the treatment must be directed to the general nervous
condition. Electricity is sometimes very beneficial, particularly the Frank-
linic form.
X. CONGENITAL AFFECTIONS OF THE HEART.
These have only a limited clinical interest, as in a large proportion of the
cases the anomaly is not compatible with life, and in others nothing can be
done to remedy the defect or even to relieve the symptoms.
The congenital affections result from interruption of the normal course
of development or from inflammatory processes — endocarditis; sometimes
from a combination of both.
{a) General Anomalies. — Of general anomalies of development the fol-
lowing conditions may be mentioned: Acardia, absence of the heart, which
has been met with in the monstrosity known by the same name; double heart,
which has occasionally been found in extreme grades of foetal deformity;
dextrocardia, in which the heart is on the right side, either alone or as part
of a general transposition of the viscera ; ectopia cordis, a condition associated
with fission of the chest wall and. of the abdomen. The heart may be situ-
ated in the cervical, pectoral, or abdominal regions. Except in the abdominal
variety the condition is very rarely compatible with extra-uterine life. Occa-
sionally, as in a case reported by Holt, the child lives for some months, and
the heart may be seen and felt beating beneath the skin in the epigastric
region. This infant was five months old at the date of examination.
( & ) Anomalies of the Cardiac Septa. — The septa of both auricles and ven-
tricles may be defective, in which case the heart consists of but two chambers,
the cor hiloculare or reptilian heart. In the septum of the auricles there is
a very common defect, owing to the fact that the membrane closing the fora-
men ovale has failed at one point to become attached to the ring, and leaves
a valvular slit which may be large enough to admit the handle of a scalpel.
Neither this nor the small cribriform perforations of the membrane are of
any significance.
The foramen ovale may be patent without a trace of membrane closing
it. In some instances this exists with other serious defects, such as stenosis
844 DISEASES OF THE CIRCULATORY SYSTEM.
of the pulmonary artery, or imperfection of tlie ventricular septum. In
others the patent foramen ovale is the only anomaly, and in many instances
it does not appear to have caused any embarrassment, as the condition has
been found in persons who have died of various affections. The ventricular
septum may be absent, the condition known as trilocular heart. Much more
frequently there is a small defect in the upper portion of the septum, either
in the situation of the membranous portion known as the " undefended space "
or in the region situated just anterior to this. The anomaly is very frequently
associated with narrowing of the pulmonary orifice or of the conus arteriosus
of the right ventricle.
(c) Anomalies and Lesions of the Valves. — Numerical anomalies of the
valves are not uncommon. The semilunar segments at the arterial orifices
are not infrequently increased or diminished in number. Supernumerary seg-
ments are more frequent in the pulmonary artery than in the aorta. Four,
or sometimes five, valves have been found. The segments may be of equal
size, but, as a rule, the supernumerary valve is small.
Instead of three there may be only two semilunar valves, or, as it is
termed, the bicuspid condition. In my experience, this is more frequent in
the aortic valve. Of 21 instances only 2 occurred at the pulmonary orifice.
Two of the valves have united, and from the ventricular face show either no
trace of division or else a slight depression indicating where the union has
occurred. From the aortic side there is usually to be seen some trace of divi-
sion into two sinuses of Valsalva. There has been a discussion as to the origin
of this condition, whether it is really an anomaly or whether it is not due to
endocarditis, foetal or post-natal. The combined segment is usually thickened,
but the fact that this anomaly is met with in the foetus without a trace of
sclerosis or endocarditis shows that it may, in some cases at least, result from
a developmental error.
Clinically this is a very important congenital defect, owing to the liability
of the combined valve to sclerotic changes. Except two foetal specimens all
of my cases showed thickening and deformity, and in 15 of those which I
have reported death resulted directly or indirectly from the lesion.
The little fenestrations at the margins of the sigmoid valves have no sig-
nificance ; they occur in a considerable proportion of all bodies.
Anomalies of the auriculo- ventricular valves are not often met with.
FcETAL ENDOCARDITIS may occur either at the arterial or aurieulo-ven-
tricular orifices. It is nearl}^ alwaj^s of the chronic or sclerotic variety. Very
rarely indeed is it of the warty or verrueose form. There are little nodular
bodies, sometimes six or eight in number, on the mitral and tricuspid seg-
ments— ^the nodules of Albini — ^which represent the remains of foetal struc-
tures, and must not be mistaken for endocardial outgrowths. The little
rounded, bead-like hsemorrhages of a deep purple color, which are very com-
mon on the heart valves of children, are also not to be mistaken for the prod-
ucts of endocarditis. In foetal endocarditis the segments are usually tliickened
at the edges, shrunken, and smooth. In the mitral and tricuspid valves the
cusps are found united and the chordge tendinese are thickened and shortened.
In the semilunar valves all trace of the segments has disappeared, leaving a
stiff membranous diaphragm perforated by an oval or rounded orifice. It
is sometimes very difficult to say whether this condition has resulted from
DISEASES OF THE HEART. 845
foetal endocarditis or whether it is an error in development. In very many
instances the processes are combined; an anomalous valve becomes the seat
of chronic sclerotic changes, and, according to Rauchfuss, endocarditis is more
common on the right side of the heart only because the valves are here more
often the seat of developmental errors.
Lesions at the Pulmonary Orifice. — Stenosis of this orifice is one of
the commonest and most important of congenital heart affections. A slow
endocarditis causes gradual union of the segments and narrowing of the orifice
to such a degree that it admits only the smallest-sized probe. In some of the
cases the smooth membranous condition of the combined segments is such that
it would appear to be the result of faulty development. In some instances
vegetations occur. The condition is compatible with life for many years,
and in a considerable proportion of the cases of heart-disease above the tenth
year this lesion is present. With it there may be defect of the ventricular
septum. Pulmonary tuberculosis is a very common cause of death. Oblitera-
tion or atresia of the pulmonary orifice is a less frequent but more serious
condition than stenosis. It is associated with persistence of the ductus arte-
riosus, together with patency of the foramen ovale or defect of the ventricular
septum with hypertrophy of the right heart. Stenosis of the conus arteriosus
of the right ventricle exists in a considerable proportion of the cases of obstruc-
tion at the pulmonary orifice. At the outset a developmental error, it may be
combined with sclerotic changes. The ventricular septum is imperfect, the
foramen ovale is usually open, and the ductus arteriosus patent. These three
lesions at the pulmonary orifice constitute the most important group of all con-
genital cardiac affections. Of 181 instances of various congenital anomalies
collected by Peacock, 119 cases came under this category, and, according to this
author, in 86 per cent of the patients living beyond the twelfth year the lesion
is at this orifice.
Congenital lesions of the aortic orifice are not very frequent., Eauchfuss
has collected 24 cases of stenosis and atresia ; stenosis of the' left conus arterio-
sus may also occur, a condition which is not incompatible with prolonged life.
Ten of the 16 cases tabulated by Dilg were over thirty years of age.
Transposition of the large arterial trunlcs is a not uncommon anomaly.
There may be neither hypertrophy, cyanosis, nor heart murmur.
Symptoms of Congenital Heart-disease. — Cyanosis occurs in over 90 per
cent of the cases, and forms so distinctive a feature that the terms " blue dis-
ease " and " morbus CEeruleus " are practically synonyms for congenital heart-
disease. The lividity in a majority of cases appears early, within the first
week of life, and may be general or confined to the lips, nose, and ears, and
to the fingers and toes. In some instances there is in addition a general dusky
suffusion, and in the most extreme grades the skin is almost purple. It may
vary a good deal and may be intense only on exertion. The external temper-
ature is low. Dyspnoea on exertion and cough are common symptoms. A
great increase in the number of the red corpuscles has been noted by Gibson
and by Vaquez. In a case of Gibson's there were above eight millions of red
blood-corpuscles to the cubic millimetre. The children rarely thrive, and often
display a lethargy of both mind and body. The fingers and toes are clubbed
to a degree rarely met with in any other affection. The cause of the cyanosis
has been much discussed. Morgagni referred it to the general congestion of
846 DISEASES OE THE CIRCULATORY SYSTEM.
fhe venous system due to obstruction, and this view was supported in a paper,
one of the ablest tbat bas been written on the subject, by Moreton Stille.
Morrisons analysis of 75 cases of congenital heart-disease shows that closure
of the pulmonary orifice with patency of the foramen ovale and the ventricular
septum is the condition most frequently associated with cyanosis, and he con-
cludes that the deficient aeration of the blood owing to diminished lung func-
tion is the most important factor. Another view, often attributed erroneously
to William Hunter, was that the discoloration was due to the admixture in the
heart of venous and arterial blood ; but lesions may exist which permit of very
free mixture without producing cyanosis. The question of the cause of cyano-
sis really can not be considered as settled. Yariot has recently made the sug-
gestion that the cause is not entirely cardiac, but is associated with disturbance
throughout the whole circulatory system, and particularly a vaso-motor paresis
and malaeration of the red blood-corpuscles.
Dia^osis. — In the case of children, cyanosis, with or without enlargement
of the heart, and the existence of a mui'mur are sufficient, as a rule, to deter-
mine the presence of a congenital heart-lesion. The cyanosis gives us no clew
to the precise nature of the trouble, as it is a symptom common to many
lesions and it may be absent in certain conditions. The murmur is usually
systolic in character. It is, however, not always present, and there are in-
stances on record of complicated congenital lesions in which the examination
showed normal heart-sounds. In two or three instances foetal endocarditis has
been diagnosed i?i gravida by the presence of a rough systolic murmur, and the
condition has been corroborated subsequent to the birth of the child. H}^er-
trophy is jsresent in a majority of the cases of congenital defect. The fatal
event may be caused by abscess of the brain. For a full discussion of the sub-
ject the senior student is referred to the exhaustive monograph of Dr. Maude
Abbott in Vol. IT of my " System of Medicine." I here abstract the conclu-
sions of Hochsinger:
" (1) In childhood, loud, rough, musical heart-murmrtrs, with normal or
only slight increase in the heart-dulness, occur only in congenital heart-disease.
The acquired endocardial defects with loud heart-murmurs in young children
are almost always associated with great increase in the heart-dulness. In the
transposition of the large arterial trunks there may be no cyanosis, no heart-
mtirmur, and an absence of hypertrophy.
" (2) In young children heart-murmurs with great increase in the car-
diac dulness and feeble apex beat suggest congenital changes. The increased
dulness is chiefly of the right heart, whereas the left is only slightly altered.
On the other hand, in the acquired endocarditis in children, the left heart is
chiefly affected and the apex beat is visible; the dilatation of the right heart
comes late and does not materially change the increased strength of the apex
beat.
*' (3) The entire absence of munnurs at the apex, with their evident pres-
ence in the region of the auricles and over the pulmonary orifice, is always an
important element in differential diagnosis, and points rather to septum defect
or pulmonary stenosis than to endocarditis.
*'' (4) An abnormally weak second pulmonic sound associated with a dis-
tinct systolic murmur is a symptom which in earh^ childliood is onl}'^ to be
explained by the assumption of a congenital ptdmonary stenosis, and possesses
DISEASES OF THE ARTERIES. 847
therefore an importance from a point of differential diagnosis which is not to
be underestimated.
" (5) Absence of a palpable thrill, despite loud murmurs which are heard
over the whole prsecordial region, is rare except with congenital defects in
the septum, and it speaks therefore against an acquired cardiac affection.
" (6) Loud, especially vibratory, systolic murmurs, with the point of
maximum intensity over the upper third of the sternum, associated with a
lack of marked sjmiptoms of hypertrophy of the left ventricle, are very impor-
tant for the diagnosis of a persistence of the ductus Botalli, and can not be
explained by the assumption of an endocarditis of the aortic valve."
Escherich suggests that the systolic basic murmur heard sometimes in the
newborn, particularly if premature, may originate in the ductus Botalli before
its closure.
Treatment. — The child should be warmly clad and guarded from all cir-
cumstances liable to excite bronchitis. In the attacks of urgent dyspnoea
with lividity blood should be freely let. Saline cathartics are also useful.
Digitalis must be used with care ; it is sometimes beneficial in the later stages.
When the compensation fails, the indications for treatment are those of valvu-
lar disease in adults.
C. DISEASES OF THE ABTERIES.
I. DEGENERATIONS.
Fatty degeneration of the intima is extremely common, and is seen in
the form of yellowish-white spots in the aorta and larger vessels. Calcifica-
iion of the arterial wall follows fatty degeneration and sclerosis, and is asso-
ciated with atheromatous changes. It occurs in the intima and the media.
In the latter it produces what is sometimes known as annular calcification,
which occurs particularly in the middle coat of medium-sized vessels and
may convert them into firm tubes. It is by no means always a senile change.
Hyaline degeneration may attack either the larger or the smaller vessels.
In the former the intima is converted into a smooth, homogeneous sub-
stance; this is commonly an initial stage of arterio-sclerosis ; here it is a
transformation of the endotheliaj lining. Of the smaller arteries and capil-
laries hyaline metamorphosis is oftenest seen in the glomeruli of the kidneys.
It is not to be confounded with the amjdoid change which is prone to occur
in the same situation. The condition is variously regarded as due to coagula-
tion of an albuminous fluid and h3^aline metamorphosis of leucocytes or of
fibrin. This substance reacts like the last with Weigert's fibrin stain.
II. ARTERIO-SCLEROSIS (Arterio-capillary Fibrosis).
The conception of arterio-sclerosis as an independent affection — a general
disease of the vascular system — is due to Gull and Sutton.
Definition. — A condition of thickening, diffuse or circumscribed, begin-
ning in the intima, consequent upon primary changes in the media and adven-
titia, but later involving the latter two coats. The process leads^ in the larger
848 DISEASES OF THE CIRCULATORY SYSTEM.
arteries, to what is known as atheroma and to endarteritis deformans, and
seriously interferes with the normal functions of various organs.
Etiolog-y. — Among the important factors in causing arterio-sclerosis the
following ma}^ be considered :
(1) Hypertension. — The degree of pressure maintained in the cardio-
vascular system, with its periodic increase with each systole, has an im-
portant influence in the production of organic changes in its walls. The
blood-pressure varies greatly in different individuals, and in the same
individual under varying conditions. There are persons with chronic hypo-
tension, perhaps associated with lowered resistance and an increased sus-
ceptibility to infectious disease. In asthenia from any cause, in the toxaemias
of t}rphoid fever, tuberculosis, and many infectious diseases the vascular ten-
sion is low. An increase in the tension is found in certain chronic diseases,
such as gout, and in the various forms of cardiac and renal disease. Much
diversity of opinion exists as to the relation of the hypertension to the struc-
tural changes; some think that the hypertension is secondary, others, notably
Allbutt, contend that it not infrequently exists jDrimarily, a view substantiated
by the recent studies in pulse tension. There are persons who show a rise in
blood-pressure at or about middle life without discoverable organic disease, and
who subsequently become subject to arterio-sclerosis and renal disease.
(2) As an involution process arterio-sclerosis is an accompaniment of old
age, and is the expression of the natural wear and tear to which the tubes are
subjected. Longevity is a vascular question, which has been well expressed in
the axiom that " a man is only as old as his arteries." To a majority of men
death comes primarily or secondarily through this portal. The onset of what
may be called physiological arterio-sclerosis depends, in the first place, upon the
quality of arterial tissue (vital rubber) which the individual has inherited,
and secondly upon the amount of wear and tear to which he has subjected it.
That the former plays a most important role is shown in the cases in which
arterio-sclerosis sets in early in life in individuals in whom none of the recog-
nized etiological factors can be found. Thus, for instance, a inan of twenty-
eight or twenty-nine may have the arteries of a man of sixty, and a man of
forty may present vessels as much degenerated as they should be at eighty.
Entire families sometimes show this tendency to early arterio-sclerosis — a
tendency which can not be explained in any other way than that in the make-
up of the machine bad material was used for the tubing. More commonly
the arterio-sclerosis results from the bad use of good vessels.
(3) Chronic Intoxications. — Alcohol, lead, and gout play an important
role in the causation of arterio-sclerosis, although the precise mode of their
action is not yet very clear. They may act, as Traube suggests, by increasing
the peripheral resistance in the smaller vessels and in this way raising the
blood tension, or possibly, as Bright taught, they alter the quality of the blood
and render more difficult its passage through the capillaries. The observations
of Cabot have thrown doubt on the importance of alcohol as a factor.
The poisons of the acute infections may produce degenerative changes in
the media and adventitia. Thayer has recently called attention to the fre-
quency of arterial changes as a sequence of typhoid fever.
(4) Syphilis is one of the most important single causes. There is a local
syphilitic arteritis most commonly seen in the aorta — a mesaortitis — ^which
DISEASES OF THE ARTERIES. 849
is a prime factor in the production of aneurism ; and there is a late diffiise
change, comparable to the parasyphilitic lesions in the nervous system.
(5) Overeating. — I am more and more impressed with the part played by
overeating in inducing arterio-sclerosis. There are many cases in which there
is no other factor. George Cheyne's advice, which I quote at page 463, was
never more needed than by the present generation.
(6) The stress and strain of modern life. — There are men in the fifth
decade who have not had syphilis or gout, who have eaten and drunk with
discretion, and in whom none of the ordinary factors are present — ^men in
whom the arterio-sclerosis seems to come on as a direct result of a high-pres-
sure life.
(7) Overwork of the muscles, which acts by increasing the peripheral re-
sistance and by raising the blood-pressure.
(8) Renal Disease. — The relation between the arterial and kidney lesions
has been much discussed, some regarding the arterial degeneration as sec-
ondary, others as primary. There are two groups of cases, one in which the
arterio-sclerosis is the first change, and the other in which it is secondary to
a primary affection of the kidneys.
Morbid Anatomy. — Thoma divides the cases into primary arterio-sclerosis,
in which there are local changes in the arteries leading to dilatation and a
compensatory increase of the connective tissue of the intima; secondary
arterio-sclerosis, due to changes in the arteries which follow increased resist-
ance to the blood-flow in the peripheral vessels. This increased tension leads
to dilatation and to slowing of the blood-stream and a secondary compensa-
tory growth of the intima.
In a study of 41 autopsies upon arterio-sclerotic cases from my wards.
Councilman follows the useful division into nodular, senile, and diffuse forms.
(a) jSTodulae Form. — In the circumscribed or nodular variety the mac-
roscopic changes are very characteristic. The aorta presents, in the early
stages, from the ring to bifurcation, numerous flat projections, yellowish or
yellowish-white in color, and situated particularly about the orifices of the
branches. In the early stage these patches are scattered and do not involve
the entire intima. In more advanced grades the patches undergo atheromatous
changes. The material constituting the button undergoes softening and breaks
up into granular material, consisting of molecular debris — the so-called
atheromatous abscess.
In the circumscribed or nodular arterio-sclerosis the primary alteration
consists in a degeneration or a local infiltration in the media and adven-
titia, chiefly about the vasa vasorum. The affection is really a mesarteritis
and a periarteritis. These changes lead to the weakening of the wall in the
affected area, at which spot the proliferative changes commence in the intima,
particularly in the subendothelial structures, with gradual thickening and the
formation of an atheromatous button or a patch of nodular arterio-sclerosis.
The researches of Thoma have shown that this is really a compensatory proc-
ess, and that before its degeneration the nodular button, which post mortem
projects beyond the lumen, during life fills up and obliterates what would
otherwise be a depression of the wall in consequence of the weakening of the
media. A similar process goes on in the smaller vessels, and in any one of
the smaller branches it can be readily seen on section that each patch of endar-
55
850 DISEASES OF THE CIRCULATORY SY STEAL
teritis corresponds to a defect in the media and often to changes in the adven-
titia. The condition is one which may lead to rapid dilatation or to the
production of an aneurism, particularly in the early stage, before the weak-
ened spot is thickened and strengthened by the intimal changes.
(&) Sexlle Aeteeio-scleeosis. — The larger arteries are dilated and tor-
tuous, the walls thin but stiff, and often converted into rigid tubes. The
sub endothelial tissue undergoes degeneration and in spots breaks down, form-
ing the so-called atheromatous abscesses, the contents of which consist of a
molecular debris. They may open into the lumen, when they are known as
atheromatous ulcers. The greater portion of the intima may be occupied by
rough calcareous plates, with here and there fissures and losses of substance,
upon which not infrequently white thrombi are deposited. Microscopically
there is extreme degeneration of the coats, particularly of the media. Senile
atrophy of the liver and kidneys usually accompanies these changes. Senile
changes are common in other organs. The heart may be small and is not
necessarily hypertrophied. In 7 of 1-i cases of Councilman's series there was
no enlargement. Brown atrophy is common.
(c) Diffuse Aeteeio-scleeosis. — The process is wide-spread throughout
the aorta and its branches, in the former usually, but not necessarily, asso-
ciated with the nodular form. The subjects of this variety are usually middle-
aged men, but it may occur early. Of the 27 in Councilman's series belong-
ing to this group the majority were between the ages of forty and fifty-five.
The youngest was a negro of twenty-three and the oldest a man of sixty.
The affection is very prevalent among negroes; less than 50 per cent were in
whites, whereas the ratio of colored to white patients in the wards is one to
seven. The affection is met with in strongly built, muscular men and, as
Councilman remarks, they rarely present on the autopsy table signs of general
anasarca or, if cedema exists, it has come on during the last few days of life.
The aorta and its branches are more or less dilated, the branches sometimes
more than the trunk. The intima may be smooth and show very slight changes
to the naked eye; more commonly there are scattered elevated areas of an
opaque white color, some of which may have undergone atheromatous changes
as in the senile form.
Microscopically in the several forms the media shows necrotic and hya-
line changes, involving in the larger arteries both muscular and elastic
elements, and the intima presents a great increase in the subendothelial con-
nective tissue, which is particularly marked opposite areas of advanced degen-
eration in the media. The small arteries — those in the kidneys, for exam-
ple— show " a thickening of the wall, due to the formation of a homogeneous
hyaline tissue vrithin the muscular coat. This tissue contains but few cells,
is faintly striated, and stains a light brown in the osmic acid used in the hard-
ening solution. In many of the smallest vessels nothing can be seen of the
elastic lamina, in others only fragments can be made out, in others it is pre-
served. . . . The muscular fibres of the media show marked atrophic changes.
Fatty degeneration of the cells can be made out both in fresh sections and
after hardening in Flemming's solution. The nuclei are thin and atrophic
and vacuoles are sometimes seen in them. In some arteries the muscle-fibres
have almost disappeared and the media is changed into a homogeneous tissue,
similar to that in the thickened intima " (Councilman). The degeneration of
DISEASES OF THE ARTERIES. 851
the media is most marked in the smaller arteries. The capillaries are thick-
ened, particularly those of the glomeruli of the kidneys, which are often oblit-
erated and involved in extensive hyaline degeneration.
It is in this group of cases that the heart shows the most important
changes. The average weight in the cases referred to was over 450 grammes,
and there were two cases in which without valvular disease the weight was
over 800 grammes. Fibrous myocarditis is often present, particularly when
the coronary arteries are involved. The semilunar valves are sometimes
opaque and sclerotic, and may be incompetent. The kidneys may show ex-
tensive sclerosis, but in many cases the changes are so slight that macroscop-
ically they might be overlooked. They may be increased in size. The capsule
is usually adherent, the surface a little rough, and very often presents atrophic,
depressed areas, deep-red in color. Increased consistence is always present.
Sclerosis of the pulmonary artery is met with in all conditions which for
a long time increase the tension in the lesser circulation, particularly in mitral
valve disease and in emphysema. Sometimes the sclerosis reaches a high grade
and is accompanied with aneurismal dilatation of the primary and secondary
branches, more rarely with insufficiency of the pulmonary valve. Leonard
Eogers has shown that in India it is not uncommon as a primary affection.
In a remarkable case of a young man of twenty-four, reported by Komberg
from Curschmann's clinic, the pulmonary arteries were involved in most ex-
tensive arterio-sclerosis ; the main branches were dilated, and the smaller
branches were the seat of the most extreme sclerotic changes. On the other
hand, the aorta and its branches were normal.
In many cases of arterio-sclerosis the condition is not confined to the
arteries, but extends not only to the capillariog but also to the veins, and may
properly be termed an angio-sclerosis.
Sclerosis of the veins — phleho-sclerosis — is not at all an uncommon accom-
paniment of arterio-sclerosis. It is seen in conditions of heightened blood-
pressure, as in the portal system in cirrhosis of the liver and in the pulmonary
veins in mitral stenosis. The afEected vessels are usually dilated, and the
intima shows, as in the arteries, a compensatory thickening, which is particu-
larly marked in those regions in which the media is thinned. The new-
formed tissue in the endophlebitis may undergo hyaline degeneration, and is
sometimes extensively calcified. In a case of fibroid obliteration of the portal
vein of long standing, I found the intima of the greatly dilated gastric, splenic,
and mesenteric veins extensively calcified. Without existing arterio-sclerosis
the peripheral veins may be sclerotic, usually in conditions of debility, but not
infrequently in young persons.
Symptoms. — Increased Tension. — The pressure with which the blood
flows in the arteries depends upon the degree of peripheral resistance and the
force of the ventricular contraction. A high-tension pulse may exist with
very little arterio-sclerosis; but, as a rule, when the condition has been per-
sistent, the sclerosis and high tension are found together. On the other hand a
very low or normal tension may be present in extremely sclerotic vessels. The
recent introduction of clinical instruments for measuring blood-pressure has
been most useful. (Consult the work of T. Janeway on Blood-Pressure.)
Hypeetrophy of the Heart. — In consequence of the peripheral resist-
ance and increased work the left ventricle increases in size, and some of the
852 DISEASES OF THE CIRCULATORY SYSTEM.
purest examples of simple hypertrophy occur in this condition. The cham-
ber may be little, if at all, dilated. The apex beat is dislocated in advanced
cases an inch or more beyond the nipple line. The impulse is heaving and
forcible. The aortic second sound is clear, ringing, and accentuated.
The early s}Tnptoms are interesting. Stengel has called attention to the
pallor, and there may be dyspeptic symptoms. It is remarkable with what
rapidity the disease may progress. I have knoT^Ti the peripheral arteries to
stiffen and grow old in a couple of years.
The combination of heightened blood-pressure, a palpable thickening of
the arteries, hypertrophy of the left ventricle, and accentuation of the aortic
second sound are signs pathognomonic of arterio-sclerosis. From this period
of establishment the course of the disease may be very varied. For years
the patient may have good health, and be in a condition analogous to that
of a person with a well-compensated valvular lesion. There may be no renal
SAinptoms. or there may be the passage of a larger amount of urine than
normal, with transient albuminuria, and now and then hyaline tube-casts.
The subsequent historj^ is extraordinarily diverse, depending upon the vas-
cular territory in which the sclerosis is most advanced, or upon the accidents
which are so liable to happen, and the symptoms may be cardiac, cerebral,
renal, etc.
(1) Cardiac. — The involvement of the coronary arteries may lead to the
various symptoms already referred to under that section — ^thrombosis with
sudden death, fibroid degeneration of the heart, aneurism of the heart, rup-
ture, and angina pectoris. Angina pectoris is not uncommon, and the organic
variety is almost always associated with arterio-sclerosis. A second impor-
tant group of cardiac s}Tnptoms results from the dilatation which finally gets
the better of the hj^Dertrophy. The patient then presents all the symptoms
of cardiac insufficiencT — dyspnoea, scant}^ urine, and very often serous effu-
sions. If the case has come under observation for the first time the clinical
picture is that of chronic valvular disease, and the existence of a loud blowing
murmur at the apex may throw the practitioner off his guard. Many cases
terminate in this way.
(2) The cerebral symptoms of arterio-sclerosis are varied and important,
and embrace those of many degenerative diseases, acute and chronic (which
follow sclerosis of the smaller branches), and cerebral hsemorrhage.
Transient hemiplegia, monoplegia, or aphasia may occur in advanced ar-
terio-sclerosis. The attacks are very characteristic, often brief, lasting twent}^-
four hours or less. Eecovery may be perfect. Eecurrence is the rule, and a
patient may have a score or more attacks of aphasia, or in the course of a
couple of years there may be half a dozen transient hemiplegic attacks or one
or two monoplegias, or paraplegia for a day or two. It is difficult to say upon
what these attacks depend. Spasm of the arteries has been suggested, but
the condition of the smallest arteries is not very favorable to this view. Pea-
body has called attention to these cases, which are more common than is
indicated in the literature. Vertigo occurs frequently, and may be either
simple, or is associated with slow pulse and syncopal or epileptiform attacks
— the Stokes- Adams syndrome.
(3) Renal s}Tnptdms supervene in a large number of the cases. A sclero-
sis, patchy or diffuse, is present in a majority of the cases at the time of
DISEASES OF THE ARTERIES. 853
autopsy, and the condition is practically that of contracted kidney. It is seen
in a typical manner in the senile form, and not infrequently develops early in
life as a direct sequence of the diffuse variety. It is often difficult to decide
clinically (and the question is one upon which good observers might not agree
in a given case) whether the arterial or the renal disease has been primary.
(4) Among other events in arterio-sclerosis may be mentioned gangrene
of the extremities, due either directly to endarteritis or to the dislodgment of
thrombi. Sudden transient paralysis may occur.
(5) Iniermittent lameness or claudication, the dysbasia angio-sclerotica of
Erb, the crural angina of Walton, is seen most frequently in connection with
arterio-sclerosis. In the horse, in which the intermittent lameness was first
described b}^ Bouley, verminous aneurisms are present in the iliac arteries. In
man Charcot described the condition in 1856 in an old soldier who was not
able to walk for more than a quarter of an hour without severe cramps in the
legs. The post mortem showed a traumatic aneurism of one iliac artery. The
loss of function and the pain in the muscles were due to the relative ischemia.
Erb has shown that intermittent lameness is not at all infrequent, particularly
, among private patients, only 3 of his 45 cases not coming in this class. Of
127 cases there were only 7 in women. Hebrews seem more frequently affected.
Sj^philis, alcohol, and tobacco are common factors. Muscular weakness after
exertion or complete disability, numbness, tingling, and paresthesia of various
forms are the common symptoms. Pulsation may be absent in the dorsal
arteries of the feet and the vessels are sclerotic. Vaso-motor changes may be
present, and in the dependent position the feet and legs become deeply
congested.
Treatment. — In the late stages the conditions must be treated as they
arise in connection with the various viscera. In the early stages, before any
local symptoms are manifest, the patient should be enjoined to live a quiet,
well-regulated life, avoiding excesses in food and drink. It is usually best to
explain frankly the condition of affairs, and so gain his intelligent co-opera-
tion. Special attention should be paid to the state of the bowels and urine,
and the secretion of the skin should be kept active by daily baths. Alcohol
in all forms should be prohibited, and the food should be restricted to plain,
wholesome articles. The use of mineral waters or a residence every year at
one of the mineral springs is usually serviceable. If there has been a syphilitic
history an occasional course of iodide of potassium is indicated, indeed, even
in the non-syphilitic cases it seems to do good, and whenever the blood-pres-
sure is high nitroglycerin or the sodium nitrite may be given.
In cases which come under observation for the first time with dyspnoea,
slight lividity, and signs of cardiac insufficiency, venesection is indicated. In
some instances, with very high tension, striking relief is afforded by the
abstraction of 20 ounces of blood.
III. ANEURISM.
The following forms of aneurism are usually recognized:
(a) The true, in which the sac is formed of one or more of the arterial
coats. This may be fusiform, cylindrical, or cirsoid (in which the dilatation
is in an artery and its branches), or it may be circumscribed or sacculated.
854 DISEASES OF THE CIRCULATORY SYSTEM.
Aneurisms are usuall}" fusiform, resulting from uniform dilatation of the
vessel, or saccular.
(&) The false aneurism, in which there is rupture of all the coats, and
the blood is free (or circumscribed) in the tissues.
(c) The dissecting aneurism, which results from injur}'' or laceration of
the internal coat. The blood dissects between the layers; hence the name,
dissecting aneurism. This occurs usually in the aorta, and may last for years,
forming when complete a double tube — the so-called double aorta.
(d) Arterio-venous aneurism results when a communication is established
between an artery and a vein, A sac may intervene, in which case we have
what is called a varicose aneurism; but in many cases the communication is
direct and the chief change is in the vein, which is dilated, tortuous, and pul-
sating, the condition being termed an aneurismal varix.
Etiology and Pathology. — An aneurism is an accident in connection with
disease of the vessel wall leading to weakness and consequent dilatation, or
to rupture. While the ordinary arterio-sclerosis may lead to aneurism, the
great majority of the cases result from the aortitis associated with s}^hilis,
which leads to loss of elasticity and local rupture. The incidence of aortic
aneurism is in the third and fourth decades, earlier than the common forms
of arterio-sclerosis. Aneurisms arise then: (a) By the gradual diffuse dis-
tention of the arterial coats, which have been weakened by arterio-sclerosis,
particularly in its early stages, before compensatory endarteritis develops. The
arch of the aorta is often dilated in this way so as to form an irregular
aneurism.
(&) In consequence of circumscribed loss of resisting power in the media
and adventitia, there is a laceration or rupture of the intima. If small this
leads to a local bulging and the gradual production of a sac; if large it may
form a dissecting aneurism, splitting the coats; or the transverse tear may
heal completely, leaving a large scar. In a case of Daland's there was just
above the aortic valves an old transverse tear of the intima, extending almost
the entire circumference of the vessel. Sclerosis of the media and adventitia
had taken place and the process was evidently of some standing. An inch
or more above it was a fresh transverse tear (or rather cut, as the edges were
as sharp as if cut with a razor) which had produced a dissecting aneurism.
This process is by no means uncommon, and occurs chiefly in the aortic arch,
very often in vessels with smooth intima.
(c) Embolic Aneurism. — When an embolus has lodged in a vessel and
permanently plugged it, aneurismal dilatation may follow on the proximal side.
The embolus itself, if a calcified fragment from a valve, may lacerate the wall,
or if infected may produce inflammation and softening.
{d)' Mycotic Aneurism. — The importance of this form has been specially
considered by Eppinger in his exhaustive monograph. The occurrence of
multiple aneurisms in malignant endocarditis has been observed by several
writers. Probably the first case in which the mycotic nature was recognized
was one which occurred at the Montreal General Hospital and is reported in
full in my lectures on malignant endocarditis. In addition to the ulceration
of the valves there were four aneurisms of the arch, of which one was large and
saccular, and three were not bigger than cherries. An extensive growth of
micrococci was present.
DISEASES OF THE ARTERIES. 855
A form of parasitic aneurism very commonly affecting the mesenteric
arteries of the horse is due to the development of the Strongylus armatus.
Thoma has described a " traction " aneurism of the concavity of the arch
at the point of insertion of the remnant of the ductus Botalli (Virchow's
Archiv, Bd. 122).
And, lastly, there are cases in which without any definite cause there is
a tendency to the occurrence of aneurisms in various parts of the body. A
remarkable instance of it in our profession was afforded by the brilliant
Thomas King Chambers, who first had an aneurism in the left popliteal artery,
eleven years subsequently an aneurism in the right leg which was cured by
pressure, and finally aneurisms of the carotid arteries.
Incidence of Aneurism. — The disease is more common in Great Britain
and in America than on the continent of Europe. The greater freqiiency in
the British army than in those of continental countries is associated with the
greater incidence of syphilis. The negroes are more affected than the whites
in the United States.
Aneurism of the Thoracic Aorta.
The causes which favor arterio-sclerosis prevail in aortic aneurism, par-
ticularly syphilis and overwork. The greatest danger probably is in strong
muscular men with commencing degenerative processes in the arteries, the
result of aortitis, who during a sudden muscular exertion are liable to lacerate
the coats, the intima not yet being strengthened by compensatory thickening
over a spot of mesarteritis. Aneurisms of the thoracic aorta are of two main
types — the diffuse dilatation and the saccular. The former is most common
in the arch, but the entire tube may be involved. The saccular variety is the
most frequent clinically; the diffuse form is often overlooked. The saccular
aneurism may be small and situated just above the aortic ring. Others form
large tumors which project externally and occupy a large portion of the upper
thorax. Small sacs from the descending portion of the arch may compress the
trachea or the bronchi. In the thoracic portion the sac may erode the vertebrae
or grow into the pleural cavity and compress the lung. It may grow through
the ribs and appear in the back.
The chief influence of an aneurism is manifested in what are known as
pressure effects. In the absence of these an aneurism may attain a large size
without producing symptoms or seriously interfering with the circulation.
Indeed, a useful clinical subdivision as given by Bramwell is into three groups
— aneurisms which are entirely latent and give no physical signs; aneurisms
which present signs of intrathoracic pressure, although it is difficult or impos-
sible to determine the nature of the lesion producing the pressure ; and, lastly,
aneurisms which produce distinct tumors with well-marked pressure symp-
toms and external signs. Broadbent makes another useful division into
aneurism of symptoms and aneurism of physical signs. It is perhaps best
to consider aneurisms of the aorta according to the situation of the tumor.
(a) Aneurisms of the Ascending Portion of the Arch. — Just above
the sinuses of Valsalva they are often small, latent, and due to syphilis.
Eupture usually takes place into the pericardium, causing instant death.
Along the convex border of the ascending part, aneurism frequently arises,
856 DISEASES OF THE CIRCULATORY SYSTEM.
and may grow to a large size^ either passing out into the right pleura or
forvard^ pointing at the second or third interspace^ eroding the ribs and ster-
num, and producing large external tumors. In this situation the sac is liable,
indeed, to compress the superior vena cava, causing engorgement of the ves-
sels of the head and arm, sometimes compressing only the subclavian vein, and
causing enlargement and oedema of the right arm. Perforation may take place
into the superior vena cava, of which accident Pepper and Griffith have col-
lected 29 cases. In rare instances, when the aneurism springs from the con-
cave side of the vessels, the tumor may appear to the left of the sternum.
Large aneurisms in this situation may cause much dislocation of the heart,
pushing it down and to the left, and sometimes compressing the inferior vena
cava, and causing swelling of the feet and ascites. The right recurrent laryn-
geal nerve is often compressed. The innominate artery is rarely involved.
Death commonly follows from rupture into the pericardium, the pleura, or
into the superior cava; less commonly from rupture externally, sometimes
from s}Ticope.
(h) AxEURisMs OF THE TRANSVERSE Arch. — The direction of their
growth is most commonly backward, but they may grow forward, erode the
sternum, and produce large tumors. The tumor presents in the middle line
and to the right of the sternum much more often than to the left, which
occurred in only -i of 35 aneurisms in this situation (0. A. Browne). Even
when small and producing no external tumor they may cause marked pressure
signs in their growth backward toward the spine, involving the trachea and
the oesophagus, and giving rise to cough, which is often of a paroxysmal char-
acter, and dysphagia. The left recurrent lar3mgeal is often involved in its
course round the arch. A small aneurism from the lower or posterior wall
of the arch may compress a bronchus, inducing bronchorrhoea, gradual bron-
chiectasy, and suppuration in the lung — a process which by no means infre-
quently causes death in aneurism, and a condition which at the Montreal Gen-
eral Hospital we were in the habit of terming aneurismal phthisis. Occa-
sionally enormous aneurisms arise in this situation, and grow into both pleurse,
extending between the manubrium and the vetebrte ; they may persist for years.
The sac may be evident at the sternal notch. The innominate artery, less com-
monly the left carotid and subclavian, may be involved in the sac, and the
radial or carotid pulse may be absent or retarded. Pressure on the sym-
pathetic may at first cause dilatation and subsequently contraction of the
pupil. Sometimes the thoracic duct is compressed.
The ascending and transverse portions of the arch are not infrequently
involved together, usually without the branches; the tumor grows upward,
or upward and to the right.
(c) Aneurisms of the Descending Portion of the Arch. — It is not
infrequently the traction aneurism of Thoma. The sac projects to the left
and backward, and often erodes the vertebrse from the third to the sixth
dorsal, causing great pain and sometimes compression of the spinal cord.
Dysphagia is common. Pressure on the bronchi ma}^ induce bronchiectasy,
with retention of secretions, and fever. A tumor may appear externall)^ in
the region of the scapula, and here attain an enormous size. Death not infre-
quently occurs from rupture into the pleura, or the sac may grow into the
lung and caujse haemoptysis.
DISEASES OF THE ARTERIES. 857
(d) Aneurisms of the Descending Thoracic Aorta. — The larger num-
ber occur close to the diaphragm^ the sac lying upon or to the left of the bodies
of the lower dorsal vertebra, which are often eroded. They are frequently
latent, and are often overlooked; pulmonary and pleural symptoms are
common. Pain in the back is severe; dysphagia is not infrequent. The
sac may reach an enormous size and form a subcutaneous tumor in' the
left back.
Physical Signs. — Inspection. — A good light is essential; cases are often
overlooked owing to a hasty inspection. The face is often suffused, the con-
junctiva injected, and veins of the chest and of one arm engorged. One
pupil may be enlarged. In many instances inspection is negative. On either
side of the sternum there may be abnormal pulsation, due to dislocation of the
heart, to deformity of the thorax, or to retraction of the lung. The aneurismal
pulsation is usually above the level of the third rib and most commonly to the
right of the sternum, either in the first or second interspace. It may be only a
diffuse heaving impulse without any external tumor. Often the impulse is
noticed only when the chest is looked at obliquely in a favorable light. When
the innominate is involved the throbbing may pass into the neck or be appar-
ent at the sternal notch. Posteriorly, when pulsation occurs, it is most com-
monly found to the left of the spine. An external tumor is present in many
cases, projecting either through the upper part of the sternum or to the
right, sometimes involving the sternum and costal cartilages on both sides,
forming a swelling the size of a cocoa-nut or even larger. The skin is thin,
often blood-stained, or it may have ruptured, exposing the lamina of the sac.
The apex beat may be much dislocated, particularly when the sac is large.
It is more commonly a dislocation from pressure than from enlargement of
the heart itself.
Palpation. — The area and degree of pulsation are best determined by pal-
pation. When the aneurism is deep-seated and not apparent externally, the
bimanual method should be used, one hand upon the spine and the other on
the sternum. There may be only a diffuse impulse. When the sac has per-
forated the chest wall the impulse is, as a rule, forcible, slow, heaving, and
expansile, and has the same qualities as a forcible apex beat. The resistance
may be very great if there are thick laminge beneath the skin; more rarely
the sac is soft and fluctuating. The hand upon the sac, or on the region in
which it is in contact with the chest wall, may feel a diastolic shock, often
of great intensity, which forms one of the valuable physical signs of aneurism.
A systolic thrill is sometimes present, not so often in saccular aneurisms as
in the dilatation of the arch. The pulsation may sometimes be felt in the
suprasternal notch.
Percussion. — The small and deep-seated aneurisms are in this respect nega-
tive. In the larger tumors, as soon as the sac reaches the chest wall, there is
produced an area of abnormal dulness, the position of which depends upon
the part of the aorta affected. Aneurisms of the ascending arch grow forward
and to the right, producing dulness on one side of the manubrium ; those from
the transverse arch produce dulness in the middle line, extending toward the
left of the sternum, while aneurisms of the descending portion most com-
monly produce dulness in the left interscapular and scapular regions. The
percussion note is flat and gives a feeling of increased resistance.
858 DISEASES OF THE CIRCULATORY SYSTEM.
Auscultation. — Adventitious sounds are not always to be heard. Even in
a large sac there may be no murmur. Much depends upon the thickness of the
laminaj of fibrin. An important sign, particularly if heard over a dull region,
is a ringing, accentuated second sound, a phenomenon rarely missed in large
aneurisms of the aortic arch. A systolic murmur may be present; sometimes
a double murmur, in which case the diastolic bruit is usually due to asso-
ciated aortic insuificiency. The systolic murmur alone is of little moment in
the diagnosis of an aneurismal sac. A continuous humming-top murmur with
systolic intensification is heard when the aneurism communicates with the
vena cava or the pulmonary artery. With the single stethoscope the shock of
the impulse with the first sound is sometimes very marked.
Among other physical signs of importance are retardation of the pulse
in the arteries beyond the aneurism, or in those involved in the sac. There
may, for instance, be a marked difference between the right and left radial,
both in volume and time. A physical sign of large thoracic aneurism, which
I have not seen referred to, is obliteration of the pulse in the abdominal aorta
and its branches. ^Lj attention was called to this in a patient who was
stated to have aortic insufficiency. There was a well-marked diastolic murmur,
but in the femorals and in the aorta I was surprised to find no trace of pul-
sation, and not the slightest throbbing in the aljdominal aorta or in the per-
ipheral arteries of the leg. The circulation was, however, unimpaired in them
and there was no dilatation of the veins. Attracted by this, I then made a
careful examination of the patient's back, when the circumstance was dis-
covered, which neither the patient himself nor any of his physicians had
noticed, that he had a very large area of pulsation in the left scapular region.
The sac probably was large enough to act as a reservoir annihilating the ven-
tricular systole, and converting the intermittent into a continuous stream.
The tracheal tugging, a valuable sign in deep-seated aneurisms, was de-
scribed by Surgeon-Major Oliver, and was specially studied by my colleagues
Eoss and MacDonnell at the Montreal General Hospital. Oliver gives the
following directions : " Place the patient in the erect position, and direct him
to close his mouth and elevate his chin to almost the full extent; then grasp
the cricoid cartilage between the finger and thumb, and use stead}^ and gentle
upward pressure on it, when, if dilatation or aneurism exists, the pulsation
of the aorta will be distinctly felt transmitted through the trachea to the
hand." This is a sign of great value in the diagnosis of deep-seated aneu-
risms, though it may occasionally be felt in tumors and in the extreme
dynamic dilatation of aortic insufficiency. It may be visible in the thyroid
cartilage. The trachea may be pushed to one side.
Occasionally a systolic murmur may be heard in the trachea, as pointed
out by David Drummond, or even at the patient's mouth, when opened. This
is either the sound conveyed from the sac, or is produced by the air as it is
driven out of the wind-pipe during the systole. Feeble respiration in one
lung is a common effect of pressure. )
Symptoms. — There ma}^ be no symptoms. A man may present a tumor
which has eroded the chest wall without pain or any discomfort. Every phys-
ical sign may be present without a single s^inptom.
An important but variable feature in thoracic aneurism is paiji, which is
particularly marked in deep-seated tumors. It is usually paroxysmal, sharp,
DISEASES OF THE ARTERIES. 859
and lancinating, often ver}^ severe when the tumor is eroding the vertehrge, or
perforating the chest wall. In the latter case, after perforation the pain may-
cease. Anginal attacks are not uncommon, particularly in aneurisms at the
root of the aorta. Frequently the pain radiates down the left arm or up the
neck, sometimes along the upper intercostal nerves. Superficial tenderness
may be felt in the skin over the heart or over the left sternomastoid muscle.
Cough results either from the direct pressure on the wind-pipe, or is associated
with bronchitis. The expectoration in these instances is abundant, thin, and
watery; subsequently it becomes thick and turbid. Paroxysmal cough of a
peculiar brazen, ringing character is a characteristic symptom in some cases,
particularly when there is pressure on the recurrent laryngeal nerves, or the
cough may have a peculiar wheezy quality — the " goose cough."
Dyspnoea, which is common in cases of aneurism of the transverse por-
tion, is not necessarily associated with pressure on the recurrent laryngeal
nerves, but may be due directly to compression of the trachea or the left
bronchus. It may occur with marked stridor. Loss of voice and hoarseness
are consequences of pressure on the recurrent laryngeal, usually the left,
inducing either a spasm in the muscles of the left vocal cord or paralysis.
Paralysis of an abductor on one side may be present without any symp-
toms. It is more particularly, as Semon states, when the paralytic contrac-
tures supervene that the attention is called to laryngeal symptoms.
HcBmorrliage in thoracic aneurism may come from (a) the soft granula-
tions in the trachea at the point of compression, in which case the sputa are
blood-tinged, hut large quantities of blood are not lost; (&) from rupture
of the sac into the trachea or a bronchus; (c) from perforation into the lung
or erosion of the lung tissue. The bleeding may be profuse, rapidly proving
fatal, and is a common cause of death. It may persist for weeks or months,
in which case it is simply hemorrhagic weeping through the s'ac, which is
exposed in the trachea. In some instances, even after a very profuse haemor-
rhage, the patient recovers and may live for years, A man with well-marked
thoracic aneurism, whom I showed to my class at the University of Pennsyl-
vania and who had had several brisk hgemorrhages, died four years after,
having in the meantime enjoyed average health. Death from hemorrhage is
relatively more common in aneurism of the third portion of the arch and of
the descending aorta.
Difficulty of swallowing is a comparatively rare symptom, and may be
due either to spasm or to direct compression. The sound should never be
passed in these cases, as the oesophagus may be almost eroded and perforation
of the sac has taken place.
Heart Symptoms. — Pain has been referred to; it is often anginal in char-
acter, and is most common when the root of the aorta is involved. The heart
is hypertrophied in less than one-half the cases. The aortic valves are some-
times incompetent, either from disease of the segment's or from stretching of
the aortic ring.
Among other signs and symptoms, venous compression, which has already
been mentioned, may involve one subclavian or the superior vena cava. A
curious phenomenon in intrathoracic aneurism is the clubbing of the fingers
and incurving of the nails of one hand, of which two examples have been
under my care, both without any special distention or signs of venous
860. DISEASES OF THE CIRCULATORY SYSTEM.
engorgement. Tumors of the arch may involve the pulmonary arterj^, pro-
ducing comjjression, or in some instances adhesion of the pulmonary segments
and insufficiency of the valve; or the sac may rupture into the artery, an
accident which happened in two of my cases, producing instantaneous death.
Pupil Symptoms. — These may be due to, first, pressure on the sympa-
thetic, which may cause dilatation of one pupil when the cord is irritated,
contraction when the nerve is paralyzed. Flushing of the side of the face
and ear, increased temperature and sweating, ma}^ be present. Secondly, as
Ainley Walker and Wall have shown, the anisocoria is most frequently due to
vascular conditions — with low blood-pressure in one carotid the pupil on that
side is dilated, with high pressure contracted, and in 26 cases of aneurism
they found a relation between the state of the ]3upil and the arteries on the
same side. Thirdly, in a few cases the anisocoria is a parasyphilitic manifesta-
tion associated with the Argyll-Eobertson phenomenon and absent knee-jerks
— the Babinski s3Tidrome.
An X-ray examination should be made in all doubtful cases. The fiuoro-
scope gives an accurate picture of the situation, the size, and the relation to
the heart. Even a small sac may be seen. In several cases I have known the
diagnosis to rest upon it alone in cases in which scarcely a physical sign was
present. Sailer and Pfahler have shown that a condition of tortuosity of the
aorta, due to arterio-sclerosis, may exist, suggesting very strongly the pres-
ence of aneurism, particularly on examination with the fluoroscope.
The clinical picture of aneurism of the aorta is extremely varied. Many
cases present characteristic symptoms and no physical signs, while others have
well-marked physical signs and no symptoms. As Broadbent remarks, the
aneurism of physical signs springs from the ascending portion of the aorta;
the aneurism of symptoms grows from the transverse arch.
Diagnosis. — Aneurism of the aorta may be confounded with: (a) The vio-
lent throbbing impulse of the arch in aortic insufficiency. I have already
referred to a case of this kind in which the diagnosis of aneurism was made
by several good observers.
(&) Simple Dynamic Pulsation. — This is common in the abdominal aorta,
but is rare in the arch. A case which came under the care of William Mur-
ray and Bramwell presented, without any pain or pressure symptoms, pulsa-
tion and dulness over the aorta. The condition gradually disappeared and
was thought to be neurotic.
(c) Dislocation of the heart in curvature of the spine may cause great
displacement of the aorta, so that it has been known to pulsate forcibly to
the right of the sternum.
{d) Solid Tumors. — When the tumor projects externally and pulsates the
difficulty may be considerable. In tumor the heaving, expansile pulsation is
absent, and there is not that sense of force and power which is so striking
in the throbbing of a perforating aneurism. There is not to be felt as in
aortic aneurism the shock of the heart-sounds, particularly the diastolic shock.
Auscultatory sounds are less definite, as large aneurisms may occur without
murmurs ; and, on the other hand, murmurs may be heard over tumors. The
greatest difficulty is in the deep-seated thoracic tumors, and here the diagnosis
may be impossible. I have already referred to the case which was regarded
'by Skoda as tumor and by Oppolzer as aneurism. The physical signs may be
DISEASES OF THE ARTERIES. 861
indefinite. The ringing aortic second sound is of great importance and is
rarely, if ever, heard over tumor. Tracheal tugging is here a valuable sign.
Pressure phenomena are less common in tumor, whereas pain is more frequent.
The general appearance of the patient in aneurism is much better than in
tumor, in which there may be cachexia and enlargement of the glands in the
axilla or in the neck. Healthy, strong males who have worked hard and have
had syphilis are the most common subjects of aneurism. Occasionally cancer
of the oesophagus may simulate aneurism, producing pressure on the left
bronchus.
(e) Pulsating Pleurisy. — In cases of empyema necessitatis, if the pro-
jecting tumor is in the neighborhood of the heart and pulsates, the condition
may readily be mistaken for aneurism. The absence of the heaving, firm dis-
tention and of the diastolic shock would, together with the history and the
existence of pleural effusion, determine the nature of the case. If necessary,
puncture may be made with a fine hypodermic needle. In a majority of the
cases of pulsating pleurisy the throbbing is diffuse and wide-spread, moving
the whole side.
Prognosis. — The outlook in thoracic aneurism is always grave. Life may
be prolonged for some years, but the patients are in constant jeopardy. Spon-
taneous cure is not very infrequent in the small sacculated tumors of the
ascending and thoracic portions. The cavity becomes filled with laminae of
firm fibrin, which become more and more dense and hard, the sac shrinks
considerably, and finally lime salts are deposited in the old fibrin. The laminae
of fibrin may be on a level with the lumen of the vessel, causing complete
obliteration of the sac. The cases which rupture externally, as a rule run a
rapid course, although to this there are exceptions; the sac may contract,
become firm and hard, and the patient may live for five, or even for ten or
twenty years. The cases which have lasted longest in my experience have
been those in which a saccular aneurism has projected from the ascending
arch. One patient in Montreal had been known to have aneurism for eleven
years. The aneurism may be enormous, occupying a large area of the chest,
and yet life be prolonged for many years, as in the case mentioned as under
the care of Skoda and Oppolzer. One of the most remarkable instances is the
case of dissecting aneurism reported by Graham. The patient was invalided
after the Crimean War with aneurism of the aorta, and for years was under
the observation of J, H. Eichardson, of Toronto, under whose care he died in
1885. The autopsy showed a healed aneurism of the arch, with a dissecting
aneurism extending the whole length of the aorta, which formed a double tube.
Treatment. — In a large proportion of the cases this can only be palliative.
Still in every instance measures should be taken which are known to promote
clotting and consolidation within the sac. In any large series of cured
aneurisms a considerable majority of the patients have not been known to be
subjects of the disease, but the obliterated sac has been found accidentally at
the post mortem.
The most satisfactory plan in early cases, when it can be carried oiit thor-
oughly, is the modified Valsalva method advised by the late Mr. Tufnell, of
Dublin, the essentials of which are rest and a restricted diet. The rest
should, as far as possible, be absolute. The reduction of the daily number of
heart-beats, when a patient is recumbent and without exertion, amounts to
862 DISEASES OF THE CIRCULATORY SYSTEM.
many thousands, and is one of the principal advantages of this plan. Mental
quiet should also be enjoined. The diet advised by Tufnell is extremely rigid
— for breakfast, 2 ounces of bread and butter and 2 ounces of milk or tea;
dinner, 3 ounces of mutton and 3 of potatoes or bread and 4 ounces of claret ;
supper, 2 ounces of bread and butter and 2 ounces of tea. This low diet
diminishes the blood-volume and is thought also to render the blood more
fibrinous. " Total per diem, 10 ounces of solid food and 8 ounces of fluid,
and no more." This treatment should be pursued for several months, but,
except in persons of a good deal of mental stamina, it is impossible to carry
it out for more than a few weeks at a time. It is a form of treatment adapted
only to the saccular form of aneurism, and in cases of large sacs communi-
cating with the aorta by a comparatively small orifice the chances of consoli-
dation are fairly good. Unquestionably rest and the restriction of the liquids
are the important parts of the treatment, and a greater variety and quantity
of food may be allowed with advantage. If this plan can not be thoroughly
carried out, the patient should at any rate be advised to live a very quiet life,
moving alwut with deliberation and avoiding all sudden mental or bodily
excitement. The bowels should be kept regular, and constipation and strain-
ing should be carefully avoided. Of medicines, iodide of potassium, as advised
by Balfour, is of great value. It may be given in doses of from 10 to 15 or
20 grains three times a da}'. Larger doses are not necessary. The mode of
action is not well understood. It may act by increasing the secretions and so
inspissating the blood, by lowering the blood-pressure, or, as Balfour thinks,
by causing thickening and contraction of the sac. The most striking effect
of the iodide in my experience has been the relief of the pain. The evi-
dence is conclusive that the syphilitic cases are more benefited by it than the
non-syphilitic. All these measures have little value unless the sac is of a
suitable form and size. The large tumors with ynde mouths communicating
with the ascending portion of the aorta may be treated on the most approved
plans for months without the slightest influence other than reduction in the
intensity of the throbbing. A patient with a tumor projecting into the right
pleura remained on the most rigid Tufnell treatment for more than one hun-
dred days, during which time he also took iodide of potassium faithfully. The
pulsations were greatly reduced and the area of dulness diminished, and we
congratulated ourselves that the sac was probably consolidating. Sudden
death followed rupture into the pleura, and the sac contained only fluid blood,
not a shred of fibrin. In cases in which the tumor is large, or in which there
seems to be very little prospect of consolidation, it is perhaps better to advise
a man to go on quietly with his occupation, avoiding excitement and worry.
Our profession has offered many examples of good work, thoroughly and con-
scientiously carried out, by men with aneurism of the aorta, who wisely, I
think, preferred, as did the late Hilton Fagge, to die in harness.
ScEGiCAL Measures. — In a few cases consolidation may be promoted in
the sac by the introduction of a foreign body, such as wire, horse-hair, or
by the combination of wiring and electrolysis. Moore, in 1864, first wired
a sac, putting in 78 feet of fine wire. Death occurred on the fifth day.
Corradi proposed the combined method of wiring with electrolysis, which
was first used by Burresi in 1879. His patient lived for three and a half
months. Horse-hair, watch-spring wire, catgut, and Florence silk have been
DISEASES OF THE ARTERIES. 863
used. Hiinner reports the statistical results of both methods up to October,
1900. With Moore's method (wiring) 14 cases were treated, 8 of thoracic
aneurism, all fatal; 6 aneurisms of the abdominal aorta, 3 of which were
successful. Of 23 cases treated by wiring and electrolysis (Moore-Corradi
method), 17 were thoracic and 6 abdominal. The thoracic cases of Eosen-
stirn, Stewart, and Kerr, and the abdominal cases of Noble and Finney
(Case V), were successful. In 8 of the 23 cases there were amelioration of
sj^mptoms and probable prolongation of life. The most favorable cases are
those in which the aneurism is sacculated, but this is a point not easily deter-
mined, and often from a sac particularly favorable for wiring there may be
secondary projections of great thinness. The sudden filling by clot of an
aneurism of the coeliac axis or of the superior mesenteric artery may result
fatally from infarct of the intestine.
Other Conditions requiring Treatment. — Pressure on veins causing en-
gorgement, particularly of the head and arms, is sometimes promptly relieved
by free venesection, and at any time during the course of a thoracic aneurism,
if attacks of dyspnoea with lividity supervene, bleeding may be resorted to with
great benefit. It has the advantage also of promptly checking the pain, for
which symptom, as already mentioned, the iodide of potassium often gives
relief. In the final stages morphia is, as a rule, necessary. Dyspnoea, if
associated with cyanosis, is best relieved by bleeding. Chloroform inhalations
may be necessary. The question sometimes comes up with reference to trache-
otomy in these cases of urgent dyspnoea. If it can be shown by laryngoscopic
examination that it is due to bilateral abductor paralysis the trachea may
be opened, but this is extremely rare, and in nearly every instance the urgent
dyspnoea is caused by pressure about the bifurcation. When the sac appears
externally and grows large, an ice-cap may be applied upon it, or a bella-
donna plaster to allay the pain. In some instances an elastic support may be
used with advantage, and I saw a physician with an enormous external aneu-
rism in the right mammary region who for many months had obtained great
relief by the elastic support, passing over the shoulder and under the arm of
the opposite side.
Digitalis, ergot, aconite, and veratrum viride are rarely, if ever, of service
in thoracic aneurism.
Aneurism of the Abdominal Aorta.
The sac is most common just below the diaphragm in the neighborhood
of the coeliac axis. This variety is rare in comparison with thoracic aneurism.
Of the 468 cases of aortic aneurism at St. Bartholomew's Hospital, 23 involved
the abdominal aorta. Seventeen cases occurred in my wards in the Johns
Hopkins Hospital in sixteen years. The tumor may be fusiform or sacculated,
and it is sometimes multiple. Projecting backward, it erodes the vertebrae
and may cause numbness and tingling in the legs and finally paraplegia, or
it may pass into the thorax and burst into the pleura. More commonly the
sac is on the anterior wall and projects forward as a definite tumor, which
may be either in the middle line or a little to the left. The tumor may project
in the epigastric region (which is most common), in the left hypochondrium,
in the left flank, or in the lumbar region. When high up beneath the pillar
of the diaphragm it may attain considerable size without being very apparent
864 DISEASES OF THE CIRCULATORY SYSTEM.
on palpation. Wlien it ruptures into the retro-peritoneal tissues tliere may
be formed gradually a tumor in the flank, which enlarges with very little
pulsation. It may be mistaken for a rapidly growing sarcoma or for appendi-
citis, and an operation may be performed.
The symptoms are chiefly pain, very often of a neuralgic nature, passing
round to the sides or localized in the back, and more persistent and intense
than in any other variety of aneurism. Gastric symptoms, particularly vomit-
ing, may be early and deceptive features. Eetardation of the pulse in the
femoral is a very common symptom.
Diagnosis and Physical Signs. — Inspection may show marked pulsation in
the epigastric region, sometimes a definite tumor. A thrill is not uncommon.
The pulsation is forcible, expansile, and sometimes double when the sac is
large and in contact with the pericardium. On palpation a definite tumor
can he felt. If large, there is some degree of dulness on percussion which
usually merges with that of the left lobe of the liver. On auscultation, a
systolic murmur is, as a rule, audible, and is sometimes best heard at the
back. A diastolic murmur is occasionally present, usually very soft in quality.
One of the commonest of clinical errors is to mistake a throbbing aorta for
an aneurism. It is to be remembered that no pulsation, however forcible, or
the presence of a thrill or a systolic murmur justifies the diagnosis of abdomi-
nal aneurism unless there is a definite tumor which can he grasped and which
has an expansile pulsation. Attention to this rule will save many errors. The
throbbing aorta — the " preternatural pulsation in the epigastrium," as Allan
Burns calls it — is met with in all neurasthenic conditions, particularly in
women. In anaemia, particularly in some instances of traumatic angemia,
the throbbing may be very great. In the case of a large, stout man with severe
hsemorrhages from a duodenal ulcer the throbbing of the abdominal aorta not
only shook violently the whole abdomen, but communicated a pulsation to
the bed, the shock of which was distinctly perceptible to any one sitting upon
it. Very frequently a tumor of the pylorus, of the pancreas, or of the' left
lobe of the liver is lifted with each impulse of the aorta and may be con-
founded with aneurism. .The absence of the forcible expansile impulse and
the examination in the knee-elbow position, in which the tumor, as a rule,
.falls forward, and the pulsation is not then communicated, suffice for differ-
entiation. The tumor of abdominal aneurism, though usually fixed, may be
very freely movable.
The outlook in abdominal aneurism is bad. A few cases heal spontane-
ously. Death may result from (a) complete obliteration of the lumen by
clots; (&) compression paraplegia; (c) rupture (which is almost the rule)
either into the pleura, retroperitoneal tissues, peritonaeum, or the intestines,
very commonly the duodenum; (d) embolism of the superior mesenteric
artery, producing infarction of the intestines.
The treatment is such as already advised in thoracic aneurism. When the
aneurism is low down pressure has been successfully applied in a case by Mur-
ray, of Newcastle. It must be kept up for many hours under chloroform.
The plan is not without risk, as patients have died from bruising and injury
of the sac. Nine cases in my series were treated surgically. In two the
wiring and electrolysis were followed by great improvement; one man lived
for three years.
DISEASES OF THE ARTERIES, 865
Aneurism of the Bkanches of the Abdominal Aorta.
The cwliac axis is itself not infrequently involved in aneurism of the
first portion of the abdominal aorta. Of its branches, the splenic artery is
occasionally the seat of aneurism. This rarely causes a tumor large enough
to be felt; sometimes, however, the tumor is of large size. I have reported
a case in a man, aged thirty, who had an illness of several months' dura-
tion, severe epigastric pain and vomiting, which led his physicians in New
York to diagnose gastric ulcer. There was a deep-seated tumor in the left
hypochondriac region, the dulness of which merged with that of the spleen.
There was no pulsation, but it was thought on one occasion that a bruit was
heard. The chief symptoms while under observation were vomiting, severe
epigastric pain, occasional haematemesis, and finally severe haemorrhage from
the bowels. An aneurism of the splenic artery the size of a cocoa-nut was
situated between the stomach above and the transverse colon below, and
extended to the right as far as the level of the navel. The sac contained
densely laminated fibrin. It had perforated the colon. I have twice seen
small aneurisms on the splenic artery. Of 39 instances of aneurism on the
branches of the abdominal aorta collected by Lebert, 10 were of the splenic
artery.
Of aneurism of the hepatic artery Rolland has collected 40 cases (1908),
of which 24 were extra-hepatic. In Eolland's case there were three sacs — all
intra-hepatic. Eupture took place in 32 cases — in 16 into the peritoneal cav-
ity, in 13 into the bile passages. The sac is rarely large, but in the case of
Wollmann's it was as large as a child's liead. . No case has been diagnosed.
Cholelithiasis and duodenal ulcer are the conditions for which it is most likely
to be mistaken. In Eoss and Osier's case the liver was enlarged, with symp-
toms of pyaemia.
Aneurism of the superior mesenteric artery is not very uncommon. The
diagnosis is scarcely possible from aneurism of the arch. Plugging of the
branches or of the main stem may cause the symptoms of infarction of the
bowels which have already been considered.
Renal Artery. — Henry Morris has collected 21 instances of aneurism, 12
of which arose from injury. Many of them were false. Pulsation and a bruit
are not always present. Four cases were operated upon; three recovered. In
a case of Keen's the tumor and the kidney were removed together,
Arterio-venous Aneurism.
In this form, known to Galen, but first accurately described by the great
William Hunter, there is abnormal communication between an artery and a
vein. When a tumor lies between the two it is known as varicose aneurism;
when there is a direct communication without tumor the vein is chiefly dis-
tended and the condition is known as aneurismal varix.
While it may occur in the aorta, it is much more common in the peripheral
arteries as a result of stab or gunshot wounds.
An aneurism of the ascending portion of the arch may open directly into
the vena cava. Twenty-nine cases of this lesion have been analyzed by Pepper
and Griffith. Cyanosis, oedema, and great distention of the veins of the upper
56
866 DISEASES OF THE CIRCULATORY SYSTEM.
part of the body are the most frequent symptoms, and develop, as a rule,
with suddenness. Of the physical signs a thrill is present in some cases. A
continuous murmur with systolic intensification is of great diagnostic value.
Thurnam (Medico-Chirurgical Transactions, 1840) gave the first accurate
account of this murmur and of this characteristic type of cyanosis. There is
only one condition with which it could be confounded, viz., the remarkable
cyanosis of the upper part of the body which follows crushing accidents to
the thorax. Perforation between the aorta and pulmonary artery causes very
much the same symptoms. In a few cases an aneurism of the abdominal aorta
perforates the inferior vena cava — oedema and cyanosis of the legs and lower
half of the body, and the distinctive thrill and murmur are present.
In the arterio-venous aneurisms which follow stab and bullet wounds of
the subclavian, axillary, carotid, femoral and popliteal arteries, the clinical
features are most characteristic. First, the veins enlarge as the arterial blood
flows under higher pressure into them. The affected limb may be greatly
swollen and in a young person may lengthen, and the growth of hair is in-
creased. Secondly, a strong thrill is felt, of maximum intensity at the site of
the aneurism, but sometimes to be felt at the most distant parts of a limb.
Thirdly, the characteristic continuous murmur with systolic intensification is
heard. In the external arteries the condition may persist for years before dis-
ability is caused by enlargement of the veins and swelling of the limb.
PoLTAETEEiTis AcuTA jSToDOSA {Periarteritis Nodosa).
A series of cases has been described in which small aneurisms occur on
the arteries of the muscles and viscera. The first case was reported by Kuss-
maul and Maier, and about 19 cases in all have been described (Dickson).
A case, agreeing clinically with the others, has occurred in my wards. No
autopsy was permitted, but the nodules were felt in the abdominal wall before
death. ,The case is reported by Sabin (J. H. H. Bulletin, 1901). There are
marked thickening of the intima and infiltration of the other coats, with a
nuclear growth almost sarcomatous. There are two theories: one that the
nodules are aneurisms due to syphilis or to congenital weakening of the
arteries; the other that they are aneurisms secondary to an infiammatory
process like the infectious granulomata.
The cases have occurred chiefly in men between the ages of twenty-seven
and fifty-two; the course is from eight to twelve weeks. The patients com-
plain of weakness. The symptoms correspond with the situation of the lesions ;
thus, their presence in the muscles is associated with pain, weakness, and
sometimes paralysis and atrophy. The nodules are abundant in the alimentary
tract. The severest symptom is epigastric pain; there is loss of appetite,
thirst, vomiting, constipation, or diarrhoea. The disease is febrile at first, but
the temperature sinks to subnormal, while the pulse remains rapid. "Wlien
the cerebral vessels are involved there are headache, excitement, convulsions,
and optic neuritis, and the diagnosis of meningitis is made. The ansemia
is extreme. In our case the haemoglobin was 21 per cent, the red blood-cells
1,704,000. The leucocytes reached 116,000, of which 91 per cent were poly-
morphonuclear forms. The urine is scanty, of low specific gravity, with albu-
min and casts. Urea is excreted in small quantities, but the mind is clear.
SECTION X.
DISEASES OF THE JSTEEYOUS SYSTEM.
A. GENERAL INTRODTJCTIOK
In" diseases of the nervous system it is of the greatest importance to know
accurately the position of the morbid process, and here, even more than in the
other departments of medicine, a thorough knowledge of anatomy and physi-
ology is essential. As it is not possible to do more than touch on the subject
in this place, for further details the student is referred to the text-books of
anatomy, physiology, and neurology.
The nervous system arises from two kinds of embryonic cells: one forms
the supporting elements or neuroglia, and the other the nerve cells proper
or neurones. The latter represent the cell units of the nervous system, and
are the only elements that discharge or carry impulses.
The Neurone. — Its Structure. — We think of the nervous system as a
combination of an immense number of these units, all having an essentially
similar structure. Each neurone is composed of a receptive cell body and of
conducting elements — namely, the protoplasmic processes or dendrites, and
the axis-cylinder process or axone. In general, it may be stated that the
dendrites conduct impulses toward the cell body (cellulipetal conduction) and
the axones conduct them away from the cell (cellulifugal conduction). De-
pending upon whether the axones conduct impulses in a direction away from
or toward the cerebrum they are called efferent or afferent. The axis-cylinder
process, after leaving the cell, gives off at varying intervals lateral branches
called collaterals, which run at right angles to the process. These collaterals,
and finally the axis-cylinder process itself, split up at their terminations into
many fine fibres, forming the end brushes. These, known as arborizations,
surround the body of one or more of the many other cells, or interlace with
their protoplasmic processes. Thus the terminals of the axone of one neu-
rone are related to the dendrites and cell bodies of other neurones by contact
(Eamon y Cajal) or by concrescence (Held). Whether or not the neurones
are organically connected with one another is still in dispute. The weight
of evidence is in favor of complete anatomical and relative physiological inde-
pendence. The studies of Apathy, Bethe, and others speak in favor of a gen-
eral interconnection by means of neurofibrils and protoplasmic bridges. These
neurofibrils traverse the dendrites and the cell body in bundles of fine fibres,
the majority of which do not anastomose, but pass through the cell body from
dendrite to dendrite or to axone, in which process they reach their clearest
867
868 DISEASES OF THE NERVOUS SYSTEM.
expression, for it consists of a bundle of closely packed fibrillsB. In the inter-
stices of the mesh of neurofibrils in the cell body proper there exist under
normal conditions islands of granular protoplasm possessing a staining reac-
tion that differs from that of the fibres themselves — the so-called "tigroid"
or Nissl bodies. The disposition of these bodies, as brought out by the methy-
lene-blue reaction, is largely useful as an index of the effect of morbid condi-
tions upon the nerve cell.
Function of the Neurone'. — As already stated, the function of the neu-
rone is to conduct nervous impulses. Their mode of action, reduced to its
simplest form, may be represented by two cells, one of which, reacting to the
environment, conducts impulses inward, whereas the other, awakened by this
afferent impulse, conducts an impulse outward. This reflex response Marshall
Hall showed to be the fundamental principle of action of the nervous system.
The environment acts on the afferent neurones through special sense organs,
so that a variety of afferent impulses, olfactory, visual, auditory, gustatory,
tactile, painful, thermic, muscular, visceral, and vascular, may be origi-
nated. The efferent neurones convey impulses outward to non-nervous tis-
sues, to the skeletal, visceral, and vascular muscles and to the secretory glands,
whose activities may thus be augmented or inhibited. The more important
reflex centres lie in the bulbo-spinal axis. The situation of the vascular and
respiratory centres in the bulb make it the vital centre of the body. In the
spinal cord the location of many reflex centres, particularly those for the mus-
cle tendons and for some of the viscera, is represented in the table on page
871. The visceral mechanism is almost wholly regulated by the bulbo-
spinal axis, and its reactions are usually unpereeived. Only in conditions of
disease do the visceral reflexes " rise into consciousness,'' and it is at such
times that the referred pains and areas of tenderness (Henry Head) are pro-
duced in the skin-fields of the spinal segments corresponding to the centre
for registration of the visceral reflex.
Degeneration and Eegeneration oe the Neurone. — The nutrition of
the neurone depends in large part upon the condition of the cell body, and
this in turn in all probability upon the activity of the nucleus. If the cell is
injured in any manner the processes degenerate, or if the processes are sepa-
rated from the cell they degenerate. Though the nerve cells cease to multiply
soon after birth, they nevertheless retain remarkable powers of growth and
repair. Injury to the cell body may not be recovered from, but if the axone
be severed and degeneration take place in consequence, it may under favorable
circumstances be replaced by sprouts from the central stump, and its function
be regained. Bethe and others believe that the peripheral section, independ-
ently of the cell body, has the power of regeneration. It is probable, however,
that both factors play a part in the regeneration — ^namely, the down growth
of the axone from the central end of the divided nerve as well as the changes
in the periphery, which are most marked in the cells of the sheath of Schwann.
Cell Systems. — The cell bodies of the neurones are collected more or less
closely together in the gray matter of the brain and spinal cord and in the
ganglia of the peripheral nerves. Their processes, especially the axis-cylinder
processes, run for the most part in the white tracts of the brain and spinal
cord and in the peripheral nerves. In this way the different parts of the
central nervous system are brought into relation with each other and with the
GENERAL INTRODUCTION.
869
rest of the body. Furthermore, the axis-cylinder processes arising from cells
subserving similar functions are apt to be collected together into bundles or
\>E G
Fig,
1. — Diagram of motor path from left brain. The upper segment is black, the lower red.
The nuclei of the motor cerebral nerves are shown in red on the right side ; on the left
side the cerebral nerves of that side are indicated. A lesion at 1 would cause upper seg-
ment paralysis in the arm of the opposite side — cerebral monoplegia ; at 3, upper segment
paralysis of the whole opposite side of the body — hemiplegia ; at 3, upper segment paral-
ysis of the opposite face, arm, and leg, and lower segment paralysis of the eye muscles
on the same side — crossed paralysis ; at 4, upper segment paralysis of opposite arm and
leg, and lower segment paralysis of the face and the external rectus on the same side —
crossed paralysis ; at 5, upper segment paralysis of all muscles below lesion, and lower
segment paralysis of muscles represented at level of lesion — spinal paraplegia ; at 6, lower
segment paralysis of muscles localized at seat of lesion — anterior poliomyelitis. (Van
Gehuchten, modified.)
870
DISEASES OF THE NERVOUS SYSTEM.
tracts, and though in many cases the course of these tracts and the functions
which they possess are extremely complicated and as yet have not been com-
pletely unravelled, nevertheless some of them are simple and fairly well under-
stood. Particularly by the study of the degenerations, that may have resulted
from injury or from the toxins of certain diseases which possess an aflfinity
for one or another of these individual tracts or systems, has it been possible
to trace the course of certain of them through the nervous system. Fortu-
nately for the clinician the best understood and the simplest system in its
arrangement is that which conveys motor impulses from the cortex to the per-
iphery— the so-called pyramidal tract.
The Motor System. — Motor impulses starting in the left side of the brain
cause contractions of muscles on the right side of the bod}', and those from
the right side of the brain in muscles of the
left side of the body. Leaving out of consid-
eration some few exceptions, it may be stated
as a general rule that the motor path is crossed,
and that the crossing takes place in the upper
segment (Figs. 1 and 2). Every muscular
movement, even the simplest, requires the ac-
tivity of many neurones. In the production
of each movement special neurones are brought
into play in a definite combination, and when-
ever these neurones act in this combination
that specific movement is the result. In other
words, all the movements of the body are rep-
resented in the central nervous system by com-
binations of neurones — ^that is, they are local-
ized. Muscular movements are localized in
every part of the motor path, so that in cases
of disease of the nervous system a study of the
motor defect often enables one to fix upon the
site of the process, and it would be hard to
over-estimate the importance of a thorough
knowledge of such localization. A voluntary
motor impulse starting from the brain cortex
must pass through at least two neurones be-
fore it can reach the muscles, and we there-
fore speak of the motor tract as being com-
posed of two segments — an upper and a
lower.
The Lower Motor Segment. — The neurones of the lower segment have
the cell bodies and their protoplasmic processes in the different levels of the
ventral horns of the spinal cord and in the motor nuclei of the cerebral nerves.
The axis-cylinder processes of the lower motor neurones leave the spinal cord
in the ventral roots and run in the peripheral nerves, to be distributed to all
the muscles of the body, where they end in arborizations in the motor end
plates. These neurones are direct — that is, their cell bodies, their processes,
and the muscles in which they end are all on the same side of the body.
The ventral roots of the spinal cord are collected, from above down, into
Fig. 2. — Diagram of motor path
from each hemisphere, show-
ing the crossing of the
path, which takes place in
the upper segment both for
the cranial and spinal nerves.
(Van Grehuchten, colored.)
GENERAL INTRODUCTION.
871
small groups, which, after joining with the dorsal roots of the same level
of the cord, leave the spinal canal between the vertebrae as the spinal
nerves. That part of the cord from which the roots forming a single
spinal nerve arise is called a segment, and corresponds to the nerve which
arises from it and not to the vertebra to which it may be opposite. With
the exception of the cervical region, in which all the nerve roots but the
eighth emerge from above the vertebrae, the roots of each segment for the
remainder of the cord leave the spinal canal below the vertebra of corre-
sponding number, and consequently, owing to the fact that during growth
the bony canal lengthens much more than the cord itself, the more tailwards
one goes the greater is the discrepancy in position between each spinal segment
and its particular vertebra. This must be borne in mind when determining
upon the site of a lesion known to occupy a given segment, for it may lie
far above the vertebra of like number and name. A chart has been prepared
from numerous measurements by Eeid showing the level of the various seg-
ments of the cord in relation to the spines of the vertebrae. The axis-cylinder
processes which go to make up any one peripheral nerve do not necessarily
arise from the same segment of the spinal cord ; in fact, most peripheral
nerves contain processes from several often quite widely separated segments.
Most of the long striped muscles, furthermore, having originated in the
embryo from more than one myatome, are innervated from more than one
, segment.
Our knowledge of the localization of the muscular movements in the gray
matter of the lower motor segment is far from complete, but enough is known
to aid materially in determining the site of a spinal lesion. A number of
tables have been prepared by different observers to represent our present knowl-
edge of this subject. They differ from each other in minor details, but agree
in the main. The following table, in which is included for each of the spinal
segments the centres of representation for the more important skeletal muscles,
the main reflex centres, and the main location of the segmental skin-field, has
been prepared from the studies of Starr, Edinger, Wichmann, Sherrington,
Bolk, and others :
LOCALIZATION OF THE FUNCTIONS IN THE SEGMENTS OF THE
SPINAL CORD.
Segment.
Striped Muscles.
Reflex.
Skin-Fields (cp. Figs.
7, AND 8).
I. II and
IIIC.
Splenius capitis.
Hyoid muscles.
Sterno-mastoid.
Trapezius.
Diaphragm (C III-V) .
Levator scapulae (C III-V).
Hypoehondrium ("?).
Sudden inspiration pro-
duced by sudden press-
ure beneath the lower
border of ribs (dia-
phragmatic).
Back of head to ver-
tex.
Neck (upper part).
JVC.
Trapezius.
Diaphragm.
Levatot scapulae.
Scaleni (C IV-T I).
Teres minor.
Supraspinatus.
Rhomboid.
Dilatation of the pupil
produced by irritation
of neck. Reflex
through the sympathe-
tic (C IV-T I).
Neck (lower part to
second rib).
Upper shoulder.
872
DISEASES OF THE NERVOUS SYSTEM.
LOCALIZATION OF THE FUNCTIONS IN THE SEGMENTS OP THE
SPINAL CORD {Continued).
Segment.
Striped Muscles.
Reflex.
Skin-Fields (cf. Figs.
7 AND 8).
V c.
Diaphragm
Scapular (C V-T I).
Outer side of shoul-
Teres minor.
Irritation of skin over the
der and upper arm
Supra and infra spinatus (C
scapula produces con-
over deltoid re-
V-VI).
traction of the scapular
gion.
Rhomboid.
muscles.
Subscapularis.
Supinator longus and
Deltoid.
biceps.
Biceps.
Tapping their tendons
Brachialis anticus.
produces flexion of
Supinator longus (C V-VII).
forearm.
Supinator brevis (C V-VII).
Pectoralis (clavicular part).
Serratus magnus.
VI c.
Teres minor and major.
Triceps. Tapping elbow
Outer side of fore-
Infraspinatus.
tendon produces exten-
arm, front and
Deltoid.
sion of forearm.
back.
Biceps.
Posterior wrist. Tap-
Outer half of hand (?).
Brachialis anticus.
ping tendons causes ex-
Supinator longus.
tension of hand (C VI-
Supinator brevis.
VII).
Pectoralis (clavicular part).
Serratus magnus (C V-VIII).
Coraco-brachialis.
Pronator teres.
Triceps (outer and long heads).
Extensors of wrist (C VI- VIII).
.vn c.
Teres major.
Scapulo-humeral. Tap-
Inner side and back
Subscapularis.
ping the inner lower
of arm and fore-
Deltoid (posterior part).
edge of scapula causes
arm.
Pectoralis major (costal part).
adduction of the arm.
Radial half of the
Pectoralis minor.
Anterior wrist. Tap-
hand.
Serratus magnus.
ping anterior tendons
Pronators of wrist.
causes flexion of wrist
Triceps.
(C VII-VIII).
Extensors of wrist and fingers.
Flexors of wrist.
Latissimus dorsi (C VI-VIII).
VIII c.
Pectoralis major (costal part).
Palmar. Stroking palm
Forearm and hand.
Pronator quadratus.
causes closure of fin-
inner half.
Flexors of wrist and fingers.
gers.
Latissimus.
Radial lumbricales and inter-
ossei.
I T.
Lumbricales and interossei.
Upper arm, inner
Thenar and hvpothenar emi-
half.
nences (C VII-T I).
II to
Muscles of back and abdomen.
Epigastric. Tickling
Skin of chest and
XII T.
Ereetores spmae (T I-LV)'.
ma mmary region
abdomen in ob-
Intercostals (T I-T XII).
causes retraction of
lique dorso-ventral
Rectus abdominis (T V-T XII).
epigastrium (T IV-
zones. The nipple
External oblique (T V-XII).
VII).
lies between the
Internal oblique (T VII-L I).
Abdominal. Stroking
zone of T IV and
Transversalis (T VII-L I).
side of abdomen causes
T V. The umbil-
retraction of belly (T
licus lies in the
IX-XII).
field of T X.
GENERAL INTRODUCTION.
873
LOCALIZATION OF THE FUNCTIONS IN THE SEGMENTS OP THE
SPINAL CORD (Continued).
Segment.
Striped Muscles.
Reflex.
Skin-Fields (cf. Figs.
7 AND 8).
XL.
Lower part of external and in-
ternal oblique and transver-
salis.
Quadratus lumborum (L I-II).
Creinaster.
Psoas major and minor (1).
Cremasteric. Stroking
inner thigh causes re-
traction of scrotum
(L I-II).
Skin over lowest ab-
dominal zone and
groin.
II L.
Psoas major and minor.
Iliacus.
Pectinens.
Sartorius (lower part).
Flexors of knee (Kemak).
Adductor longus and brevis.
Front of thigh.
Ill L.
Sartorius (lower part).
Adductors of thigh.
Quadriceps femoris (L II-L IV).
Inner rotators of thigh.
Abductors of thigh.
Patellar tendon. Tap-
ping tendon causes ex-
tension of leg. " Knee-
jerk."
Front and inner side
of thigh.
IV L.
Plexors of knee (Perrier).
Quadriceps femoris.
Adductors of thigh.
Abductors of thigh.
Extensors of ankle (tibialis anti-
cus).
Glutei (medius and minor).
Gluteal. Stroking but-
tock causes dimpling
in fold of buttock
(L IV-V).
Mainly inner side of
thigh and leg to
ankle.
V L.
Flexors of knee (ham-string
muscles) (L IV-S II).
Outward rotators of thigh.
Glutei.
Plexors of ankle (gastrocnemius
and soleus) (L IV-S II).
Extensors of toes (L IV-S I).
Peronsei.
Back of leg, and part
of foot.
I to
II S.
Flexors of ankle (L V-S II).
Long flexor of toes (L V-S II).
Peronsei.
Intrinsic muscles of foot.
Foot reflex. Extension
of Achilles tendon
causes flexion of ankle
(S I-II). Ankle-clonus.
Plantar. Tickling sole
of foot causes flexion
of toes or extension of
great toe and flexion
of others.
Back of thigh, leg,
and foot ; outer
side.
Ill to
V s.
Perineal muscles.
Levator and sphincter ani (S I-
III).
Vesical and anal reflexes.
Skin over sacrum
and buttock.
Anus.
Perinaeum. Genitals.
The Upper Motor Segment and Motor Areas of the Cortex. — The
cell bodies of the upper motor neurones are found in the brain cortex lying
for the rriost part in a strip anterior to the fissure of Eolando, and it is in
this region that we find the movements of the body again represented.
The clinical studies of Hughlings Jackson, the experiments of Hitzig and
Fritsch and of Ferrier, and the anatomical studies of tract myelinization by
874
DISEASES OF THE NERVOUS SYSTEM.
Flechsig, laid the foundation for the great mass of most excellent work which
has been done upon this subject. We owe much to Victor Horsley and his asso-
ciates for their careful researches in this direction. More recently the experi-
mental work of Sherrington and Griinbaum on the higher apes has somewhat
modified the observations of preceding investigators, and with the result of
more accurately delineating the motor territor}'. They have shown that true
motor responses are elicited only by stimulation anterior to the Eolandic fissure;
that practically no point, over the ascending frontal convolution, fails to re-
FiG. 3. — Diagrammatic representation of cortical localization in the left hemisphere, showing
the speech centres. The motor areas determined by unipolar faradic excitation of the
anthropoid cortex (Sherrington and G-riinbaum) are here shown stippled in red and lie
anterior to the Rolandic fissure. The sensory areas presumably lie posterior to this fis-
sure and are roughly indicated in blue without accurate delineation. Lying as it does
on the upper surface of the hemisphere, the leg area should not be visible on a lateral
view such as is given here.
spend to stimulation : that there is but slight extension of the motor cortex on
to the paracentral lobule of the mesial surface of the brain; that movements
are obtainable not only from the exposed part of the convolution, but also from
its hidden surface to the very depths of the Rolandic sulcus; that there is an
area of representation for the trunk between the centres for the leg and arm,
and also for the neck between those of the arm and face; that the superior
and inferior genua are the landmarks which indicate the situation of these
small areas of representation for trunk and neck. These results .have in large
GENERAL INTRODUCTION,
875
measure been confirmed by Gushing by unipolar electrical stimulation of
the human cortex in a number of brain cases that have been operated upon
from my clinic. From above down the motor areas occur in the following
order : leg, trunk, arm, neck, head ( Fig. 3 ) . Those of the leg and arm occupy
the upper half of the convolution, and that for the head, including movements
of the face, jaws, tongue, and larynx, the lower half.
The speech centres are indicated in the diagram (Fig. 3) in accordance
with the generally accepted views : that for motor speech occupies the posterior
part of the left third frontal or Broca's convolution. It is a disputed point
whether or not there is a separate centre presiding over the movements em-
ploj^ed in writing. Some have assumed such
a centre to be present in the second frontal
convolution as indicated on the diagram.
The conjugate movement of head and eyes
to the opposite side has commonly been found
in apes to follow stimulation of the external
surface of the frontal lobe. Similarly move-
ments of the eyes may be elicited from the
occipital cortex, but probably none of these
reactions are comparable to the more simple
movements through the pyramidal tract which
follow stimulation of the ascending frontal
convolution.
The axis-cylinder processes of the upper
motor neurones after leaving the gray matter
of the motor cortex pass into the white mat-
ter of the brain and form part of the corona
radiata. They converge and pass between the
basal ganglia in the internal capsule. Here
the motor axis-cylinders are collected into a
compact bundle — the pyramidal tract — occu-
pying the knee and anterior two-thirds of the
posterior limb of the internal capsule. The
■order in which the movements of the oppo-
site side of the body are represented at this
level, as learned from experimental observa-
tions on apes, is given in Fig. 4.
After passing through the internal cap-
sule the fibres of the pyramidal tract leave the hemisphere by the crus, of
which they occupy about the middle three-fifths (Fig. 5). The movements
of the tongue and lips are represented nearest the middle line.
As soon as the tract enters the crus, some of its axis-cylinder processes
leave it and cross the middle line to end in arborizations about the ganglion
•cells in the nucleus of the third nerve on the opposite side; and in this way,
as the pyramidal tract passes down, it gives ojff at different levels fibres which
end in the nuclei of all the motor cerebral nerves on the opposite side of the
body. Some fibres, however, go to the nuclei of the same side (Hoche).
From the crus, the pyramidal tract runs through the pons and forms in the
medulla oblongata the pyramid, which, gives its name to the tract. At the
Fig. 4. — Diagram of motor and sen-
sory representation in the inter-
nal capsule. NL., Lenticular
nucleus. NC, Caudate nucleus,
THO., Optic thalamus. The mo-
tor paths are red and black, the
sensory are blue.
876
DISEASES OF THE NERVOUS SYSTEM.
Fig. 5. — Diagram of motor and sensory paths in Crura.
lower part of the medulla, after the fibres going to the cerebral nerves have
crossed the middle line, a large proportion of the remaining fibres cross,
decussating with those from the opposite p3'ramid. and pass into the opposite
side of the spinal cord, forming the crossed p3Tamidal tract of the lateral
column (fasciculus cerebro-
spinalis lateralis) (Fig. 6,
1 ) . The smaller number of
fibres which do not at this
time cross, descend in the
ventral column of the same
side, forming the direct
pyramidal tract, or Tiirck's
column (fasciculus cerebro-
spinalis ventralis) (Fig. 6,
At every level of the
spinal cord axis-cylinder
processes leave the crossed
pyramidal tract to enter the
ventral horns and end about
the cell bodies of the lower motor neurones. The tract diminishes in size
from above downward. The fibres of the direct pyramidal tract cross at
different levels in the ventral white commissure, and also, it is believed, end
about cells in the ventral
horns on the opposite side of
the cord. This tract usually
ends about the middle of the
thoracic region of the cord.
The Sensory System. —
The path for sensory conduc-
tion is more complicated than
the motor path, and in its
simplest form is composed of
at least three sets of neu-
rones, one above the other.
The cell bodies of the lowest
neurones are in the ganglia,
on the dorsal roots of the
spinal nerves, and the gan-
glia of the sensory cerebral
nerves. These ganglion cells
have a special form, having
apparently but a. single proc-
ess, which, soon after leav-
ing the cell, divides in a T-
shaped manner, one portion running into the central nervous system and
the ot]ier to the periphery of the body. Embryological and comparative
anatomical studies have made it seem probable that the peripheral sensory
fibre, the process which conducts toward the cell, represents the protoplasmic
Fig. 6. — Diagram of cross-section of spinal cord, show-
ing motor, red, and sensory, blue paths. 1, Lateral
pyramidal tract. 2, "Ventral pyramidal tract. 3,
Dorsal columns. 4, Direct cerebellar tract. 5
Ventro-lateral ground bundles. 6, Ventro-lateral
ascending tract of Gowers. (Van Gehuchten,
colored.)
GENERAL INTRODUCTION. 877
processes, while that which conducts away from the cell is the axis-cylinder
process. In the peripheral sensory nerves we have, then, the dendrites of the
lower sensory neurones. These start in the periphery of the body from their
various specialized end organs. The axis-cylinder processes leave the ganglia
and enter the spinal cord by the dorsal roots of the spinal nerves. After enter-
ing the cord each axis-cylinder process divides into an ascending and a
descending branch, which run in the dorsal fasciculi. The descending branch
runs but a short distance, and ends in the gray matter of the same side of
the cord. It gives off a number of collaterals, which also end in the gray
matter. The ascending branch may end in the gray matter soon after enter-
ing, or it may run in the dorsal fasciculi as far as the medulla to end about
the nuclei there. In any case it does not cross the middle line. The lower
sensory neurone is direct.
The cells about which the axis-cylinder processes and their collaterals of
the lower sensory neurone end are of various kinds. They are known as sen-
sory neurones of the second order. In the first place, some of them end about
the cell bodies of the lower motor neurones, forming the path for reflexes.
They also end about cells whose axis-cylinder processes cross the middle line
and run to the opposite side of the brain. In the spinal cord these cells are
found in the different parts of the gray matter, and their axis-cylinder proc-
esses run in the opposite ventro-lateral ascending tract of Gowers (Fig. 6, 6)
and in the ground bundles (fasciculus lateralis proprius and fasciculus ven-
tralis proprius).
In the medulla the nuclei of the dorsal fasciculi (nucleus fasciculi gra-
cilis (Golli) and nucleus fasciculi cuneati (Burdachi)) contain for the most
part cells of this character. Their axis-cylinder processes, after crossing, run
toward the brain in the medial lemniscus or bundle of the fillet; certain of
the longitudinal bundles in the formatio reticularis also represent sensory
paths from the spinal cord and medulla toward higher centres. The fibres
of the medial lemniscus or fillet do not, however, run directly to the cere-
bral cortex. They end about cells in the ventro-lateral portion of the optic
thalamus, and the tract is continued on by way of another set of neurones,
which send processes to end in the cortex of the posterior central and parietal
convolutions. This is the most direct path of sensory conduction, but by no
means the only one. The peripheral sensory neurones may also end about
cells in the cord whose axones run but a short distance toward the brain before
ending again in the gray matter, and the path, if path it can be called, is
made up of a series of these superimposed neurones. The gray matter of
the cord itself is also believed to offer paths of sensory conduction. All these
paths reach the tegmentum and optic thalamus, and thence are distributed
to the cortex along with the other sensory paths. There may also be paths
of sensory conduction through the cerebellum by way of the direct cerebellar
tract and Gowers' bundle.
From this short summary it is evident that the possible paths for the
conduction of afferent impulses are many, and become more complex as the
various tracts approach the brain where our knowledge of them is somewhat
indefinite. The anatomical arrangement of the two lower orders of sensory
neurones is, however, sufficiently well understood to be of great clinical value.
We have seen in the case of the motor neurones that the distribution of the
878
DISEASES OF THE NERVOUS SYSTEM.
Fig. 7.— Anterior aspect of the segmental skin-fields of the body, combined from the studies
of Head, Kocher, Starr, Thorburn, Edinger, Sherrington, Wichmann, Seiffer, Bolk,
Cashing, and others. Heavy lines represent levels of fusion of dermatomes and the pre-
axial and postaxial lines of the limbs.
GENERAL INTRODUCTION.
879
YiQ. 8.— Posterior aspect of the segmental skin-fields of the body.
880 DISEASES OF THE NERVOUS SYSTEM.
peripheral nerves to the muscles, owing largely to the interlacing into plexuses
of the neurones from the yarious spinal units, is quite different from that of
the ventral roots themselves, and the same rule holds true for the peripheral
nerve and dorsal root distribution for the cutaneous areas. The cutaneous
fields corresponding to the peripheral nerves are well known, and although
our knowledge of the exact site and outline of some of the segmental skin-
fields, represented by the dorsal roots, is less accurately established, neverthe-
less they are sufficiently well understood to be of aid in determining the
segmental level of spinal cord and of dorsal root lesions. Information con-
cerning the topography in the adult of these skin units or dermatomes has
been obtained from various sources; from morphological studies; from ana-
tomical dissections; from physiological experimentation, particularly in Sher-
rington's hands; from the study of anesthesias in clinical cases after trau-
matic injuries to the cord, by Starr, Thorburn. Kocher, and many others ;
and lastly from Head's studies of the distribution of the cutaneous lesions in
herpes zoster, and of the areas of referred pain and tenderness in visceral
disease. The diagrams on pages 878 and 879 embody the results of many
of these observations.
The cutaneous sensory impressions are in man conducted toward the brain,
probably on the opposite side of the cord — that is, the path crosses to the
opposite side soon after entering the cord. Muscular sense, on the other hand,
is conducted on the same side of the cord in the fasciculus of Goll. to cross
above by means of the axones of sensory neurones of the second order in the
medulla.
Sensory Areas of the Cortex. — The localization of sensory impressions
in the cortex of the brain is not definitely determined, but it is believed to be
posterior to the motor representation. Sensation seems, however, to be more
widely represented than motion, and to occupy most of the parietal lobe as
well as the posterior central convolutions (Fig. 3).
The paths for the conduction of the stimuli which underlie the special
senses are given in the section upon the cerebral nerves, and it is only neces-
sary here to refer to what is known of the cortical representation of these
senses.
Visual impressions are localized in the occipital lobes. The primarv visual
centre is on the mesial surface in the cuneus, especially about the calcarine
fissure, and here are represented the opposite visual half -fields. Some authors
believe that there is another higher centre on the outer surface of the occipital
lobe, in which the vision of the opposite eye is chiefly represented. However
this may be, most authors hold that the angular gyrus of the left hemisphere
is a part of the brain in which are stored the memories of the meaning of
letters, words, figures, and indeed of all seen objects. This is designated as
the visual speech centre on the diagram (Fig. 3). Flechsig and Monakow
do not admit this.
Auditory impressions are localized for the most part in the first temporal
convolution and the transverse temporal gyri, and it is in this region in the
left hemisphere that the memories of the meanings of heard words and sounds
are stored. Musical memories are localized somewhat in front of those for
words. The cortical centres for smell include a part of the base of the frontal
lobe, the iincus, and perhaps the gyrus hippocampi. The centres for taste
GENERAL INTRODUCTION. 881
are supposed to be situated near those for smell, but we possess as yet no
definite information about them.
Topical Diagnosis. — The successful diagnosis of the position of a lesion
in the nervous system depends upon a careful and exhaustive examination into
all the symptoms that are present, and then endeavoring with the help of
anatomy and physiology to determine the place, a disturbance at which might
produce these symptoms.
The abnormalities of motion are usually the most important localizing
symptoms, both on account of the ease with which they can be demonstrated,
and also because of the comparative accuracy of our knowledge of the motor
path.
Lesions in any part of the motor path cause disturbances of motion. If
destructive, the function of the part is abolished, and as the result there is
paralysis. If, on the other hand, the lesion is an irritative one, the structures
are thrown into abnormal activity, which produces abnormal muscular con-
traction. The character of the paralysis or of the abnormal muscular contrac-
tion varies with lesions of the upper and lower segment, the variations
depending, first, upon the anatomical position of the two segments; and, sec-
ondly, upon the symptoms which are the result of secondary degeneration in
each of the segments.
(a) Lesions of the Lower or Spino-muscular Segment. — Destructive
Lesions. — It has been stated above that the nutrition of all parts of a neurone
depends upon their connection with its healthy cell body; and if the cell body
be injured, its processes undergo degeneration, or if a portion of a process be
separated from the cell body, that part degenerates along its whole length.
This so-called secondary degeneration plays a very important role in the
symptomatology.
In the lower motor segment the degeneration not only affects the axis-
cylinder processes which run in the peripheral nerves, but also the muscle
fibres in which the axis-cylinder processes end. The degeneration of the nerves
and muscles is made evident, first, by the muscles becoming smaller and flabby,
and, secondly, by change in their reaction to electrical stimulation. The
degenerated nerve gives no response to either the galvanic or the faradic cur-
rent, and the muscle does not respond to faradic stimulation, but reacts in
a characteristic manner to the galvanic current. The contraction, instead
of being sharp, quick, lightning-like, as in that of a normal muscle, is slow
and lazy, and is often produced by a weaker current, and the anode-closing
contraction may be greater than the cathode-closing contraction. This is the
reaction of degeneration, but it is not always present in the classical form!
The essential feature is the slow, lazy contraction of the muscle to the galvanic
current, and when this is present the muscle is degenerated.
The myotatic irritability, or muscle reflex, and the muscle tonus depend
upon the integrity of the reflex arc, of which the lower motor segment is the
efferent limb, and in a paralysis due to lesion of this segment the muscle
reflexes (tendon reflexes) are abolished and there is a diminished muscular
tension.
Lower segment paralyses have for their characteristics degenerative atrophy
with the reaction of degeneration in the affected muscles, loss of their reflex
excitability, and a diminished muscular tension. These are the general char-
57
882 DISEASES OF THE NERVOUS SYSTEM.
acteristics, but the anatomical relations of this segment also give certain
peculiarities in the distribution of the paralyses which help to distinguish
them from those which follow lesions of the upper segment, and which also
aid in determining the site of the lesion in the lower segment itself. The
cell bodies of this segment are distributed in groups, from the level of the
peduncles of the brain throughout the whole extent of the spinal cord to its
termination opposite the second lumbar vertebra, and their axis-cj^inder proc-
esses run in the peripheral nerves to every muscle in the body; so that the
component parts are more or less widely separated from each other, and a
local lesion causes paralysis of only a few muscles or groups of muscles, and
not of a whole section of the body, as is the case where lesions afEect the upper
segment. The muscles which are paralyzed indicate whether the disease is in
the peripheral nerves or spinal cord; for, as we have seen above, the muscles
are represented differently in the peripheral nerves and in the spinal cord.
Sensory symptoms, which may accompany the paralysis, are often of great
assistance in making a local diagnosis. Thus, in a paralysis with the char-
acteristics of a lesion of the lower motor segment, if the paralyzed muscles are
all supplied by one nerve, and the ansesthetic area of the skin is supplied by
that nerve, it is evident that the lesion must be in the nerve itself. On the
other hand, if the muscles paralyzed are not supplied by a single nerve, but
are represented close together in the spinal cord, and the anaesthetic area
corresponds to that section of the cord (see table), it is equally clear that the
lesion must be in the cord itself or in its nerve roots.
Ieritative Lesions of the Lower Motor Segment. — Lesions of this
segment cause comparatively few symptoms of irritation, and our knowledge on
this point is neither extensive nor accurate. The fibrillary contractions which
are so common in muscles undergoing degeneration are probably due to stimu-
lation of the cell bodies in their slow degeneration, as in progressive muscular
atrophy, or to irritation of the axis-cylinder processes in the peripheral nerves,
as in neuritis. Lesions which affect the motor roots as they leave the central
nervous system may cause spasmodic contractions in the muscles supplied by
them. Certain convulsive paroxysms, of which laryngismus stridulus is a
type, and to which the spasms of tetany also belong, are believed to be due to
abnormal activity in the lower motor centres. These are the " lowest level fits "
of Hughlings Jackson. Certain poisons, as strychnia and that of tetanus, act
particularly upon these centres.
The principal diseases in which the lower motor segment may be involved
are : all diseases involving the peripheral nerves, cerebral and spinal meningitis,
injuries, hgemorrhages and tumors of the medulla and cord or their membranes,
lesions of the gray matter of the segment, anterior poliomyelitis, progressive
muscular atrophy, bulbar paralysis, ophthalmoplegia, syringomyelia, etc.
(&) Lesions op the Upper Motor Segment. — Destructive lesions cause
paralysis, as in the lower motor segment, and here again the secondary degen-
eration which follows the lesion gives to the paralysis its distinctive character-
istics. In this case the paralysis is accompanied by a spastic condition,
shown in an exaggeration of muscle reflex and an increase in the tension of
the muscle. It is not accurately known how the degeneration of the pyramidal
fibres causes this excess of the muscle reflex. The usual explanation is, that
under normal circumstances the upper motor centres are constantly exerting
GENERAL INTRODUCTION. 883
a restraining influence upon the activity of the lower centres, and that when
the influence ceases to act, on account of disease of the pyramidal fibres, the
lower centres take on increased activity, which is made manifest by an exag-
geration of the muscle reflex.
We have seen that the neurones composing each segment of the motor path
are to be considered as nutritional units, and therefore the secondary degen-
eration in the upper segment stops at the beginning of the lower. For this
reason the muscles paralyzed from lesions in the upper segment do not undergo
degenerative atrophy, nor do they show any marked change in their electrical
reactions.
The separate parts of the upper motor segment lie much more closely
together than do those of the lower segment, and therefore a small lesion
may cause paralysis in many muscles. This is more particularly true in the
internal capsule, where all the axis-cylinder processes of this segment are col-
lected into a compact bundle — the pyramidal tract. A lesion in this region
usually causes paralysis of most of the muscles on the opposite side of the
body — that is, hemiplegia. The pyramidal tract continues in a compact bundle,
giving off fibres to the motor nuclei at different levels; a lesion anywhere in
its course is followed by paralysis of all the muscles whose spinal centres
are situated below the lesion. When the disease is above the decussation, the
paralysis is on the opposite side of the body ; when below, the paralyzed muscles
are on the same side as the lesion. Above the internal capsule the path is some-
what more separated, and in the cortex the centres for the movements of the
different sections of the body are comparatively far apart, and a sharply local-
ized lesion in this region may cause a more limited paralysis, affecting a limb
or a segment of a limb — the cerebral monoplegias ; but even here the paralysis
is not confined to an individual muscle or group of muscles, as is commonly
the case in lower segment paralysis (see Fig. 1 and explanation).
To sum up, the paralyses due to lesions of the upper motor segment are
wide-spread, often hemiplegic; the paralyzed muscles are spastic (the tendon
reflexes exaggerated), they do not undergo degenerative atrophy, and they
do not present the degenerative reaction to electrical stimulation.
There is an exception to the above statement — that is, in the paralyses
which follow a complete transverse lesion of the spinal cord. Here the limbs
are of course completely paralyzed, but instead of being spastic they are flaccid
and the deep reflexes are absent. The muscles react normally to electricity.
There is no satisfactory explanation of the loss of the reflexes under these
conditions.
Irritative Lesions of the Upper Motor Segment. — Our knowledge
of such lesions is confined for the most part to those acting on the motor cor-
tex. The abnormal muscular contractions resulting from lesions so situated
have as their type the localized convulsive seizures classed under Jacksonian or
cortical epilepsy, which are characterized by the convulsion beginning in a
single muscle or group of muscles and involving other muscles in a definite
order, depending upon the position of their representation in the cortex.
For instance, such a convulsion, beginning in the muscles of the face, next
involves those of the arm and hand, and then the leg. The convulsion is
usually accompanied by sensory phenomena and followed by a weakness of
the' muscles involved.
884 DISEASES OF THE NERVOUS SYSTEM.
A majorit}' of lesions of the motor cortex are both destructive and irri-
tative— i. e., they destroy the nerve cells of a certain centre, and either in their
growth or by their presence throw into abnormal activity those of the sur-
rounding centres.
The upper motor segment is involved in nearly all the diseases of the
brain and spinal cord, especially in injuries, tumors, abscesses, and haemor-
rhages; transverse lesions of the cord; syringomyelia, progressive muscular
atrophy, bulbar paralysis, etc. One lesion often involves both the upper and
the lower motor segments, and we have paralysis in the different parts of the
body, with the characteristics of each. Such a combination enables us in
many cases to make an accurate local diagnosis.
Lesions in the optic path and in the different speech centres also give
localizing symptoms, which should always be looked for.
(c) Lesioxs of the Sexsort Path. — Here again the lesion may be either
irritative or destructive. Irritative lesions cause abnormal subjective sensory
impressions — para?sthesia, formication, a sense of cold or constriction, and
pain of every grade of intensity. The character of the sensory symptoms gives
very little indication as to the position of the irritating process. Intense pain
is, as a rule, a symptom of a lesion in the peripheral sensory neurones, but it
may be caused by a disease of the sensory path within the central nervous
system.
The exact distribution of symptoms gives us more accurate data, for if
they are confined to the distribution of a peripheral nerve or of a spinal seg-
ment the indication is plain. If one side of the body is more or less completely
affected, we must think of a lesion somewhere within the brain, etc.
Destructive Lesions. — A complete destruction of the sensory paths from
any part of the body would of course deprive that part of sensation in all its
qualities. This occurs most frequently from injury to the peripheral sensory
neurones within the peripheral nerves, and the area of antesthesia depends
upon the nerve injured. Complete transverse lesion of the cord causes com-
plete anassthesia below the injury.
Unilateral lesions of the cord, medulla, dorsal part of the pons, tegmentum,
thalamus, internal capsule, and cortex cause disturbances of sensation on the
opposite side of the body; here again the extent of the defect more than its
character helps us to determine the position of the lesion. HemiauEesthesia in-
volving the face as well as the rest of the body can only occur above the place
where the sensory paths from the fifth nerve have crossed the middle line on
their way to the cortex. This is in the upper part of the pons. From this
point to where they leave the internal capsule the sensory paths are in fairly
close relation, and are at times involved in a very small lesion. Above the
internal capsule the paths diverge quickly, and for. this reason only an exten-
sive lesion can involve them all, and in lesions of this part we are more
apt to have the sensory disturbances confined to one or another region of
the body. Unilateral lesions of the pons, medulla, and cord usually cause
sensory disturbances on the same side of the body, as well as those on the
opposite side. These are due to the involvement of the sensory paths as
they enter the central nervous system at or a little below the site of the
lesion and before the axones of the sensory neurones of the second order have
crossed the middle line. The area of disturbed sensation on the same side is
SYSTEM DISEASES. 885
limited to the distribution of one or more spinal segments and often indicates
accurately the position and extent of the diseased process. As a rule, destruc-
tive lesions of the central nervous system do not involve all the paths of
sensory conduction, and the loss of sensation is not complete. It is often
astonishing how very slight the sensory disturbances are which result from
an extensive lesion. Sensation may be diminished in all of its qualities,
or, what is more common, certain qualities may be affected while others
are normal. These cases of dissociation of sensation, or so-called elective
sensory paralysis, have been much studied of late. Thus the sense of pain
and temperature may be lost while that of touch remains normal, as is often
the case in diseases of the spinal cord, or there may be simply a loss of the
muscular sense and of the stereognostic sense (the complex sensory impression
which enables one to recognize an object placed in the hand), as occurs fre-
quently from lesions of the cortex. Occasionally pain sensation persists with
loss of tactile and thermic sensations. Almost every other combination has
been described. It is the distribution more than the character of the sensory
defect that is of importance, and often the distribution gives but uncertain
indication of the position of the lesion. The combination of the sensory defect
with different forms of paralysis gives the most certain diagnostic signs. The
student is referred to the sections on the individual parts of the nervous sys-
tem for a more detailed consideration of the subject.
B. SYSTEM DISEASES.
I. INTRODUCTION.
There are certain diseases of the nervous system which are confined, if
not absolutely, still in great part, to definite tracts (combinations of neurones)
which subserve like functions. These tracts are called systems, and a disease
which is confined to one of them is a system disease. If more than one system
is involved, the process is called a combined system disease. Just what dis-
eases should be classed under these names has given rise to much discussion
but to very little agreement. We can not speak positively; our knowledge is
as yet not sufficiently accurate, either in regard to the exact limits of the sys-
tems themselves, or to the nature and extent of the morbid process in the
several diseases. In the classification which has been adopted in this edition
the endeavor has been to make the arrangement as simple as possible, and,
while it is based upon what is believed to be the best founded views of the
systems and their diseases, there has been no attempt to carry the classification
to its logical conclusion, nor have the limits of the theory been always
respected.
In general it may be said that the nervous system is composed of two great
systems of neurones, the afferent or sensory system and the efferent or motor
system, and the connections between them. (See General Introduction.)
Locomotor ataxia is a disease confined at its onset to the afferent system,
and progressive muscular atrophy is one of the efferent system. Eepresenting
typical system diseases as we now understand them, they have been taken as
the basis of the classification. Several theories have been advanced to explain
886 DISEASES OF THE NERVOUS SYSTEM.
why a disease should be limited to a definite system of neurones. One view is
based upon the idea that in certain individuals one or the other of these sys-
tems has an innate tendency to undergo degeneration; another assumes that
neurones with a similar function have a similar chemical construction (which
differs from that of neurones with a different function), and this is taken to
explain why a poison circulating in the blood should show a selective action for
a single functional system of neurones.
In the afferent tract locomotor ataxia stands alone as a system disease,
and we now believe that herpes zoster is an inflammation of the dorsal root
ganglia and stands in the same relation to tabes that acute anterior polio-
myelitis does to chronic progressive muscular atrophy. In the efferent tract
progressive (central) muscular atrophy is the chief representative, as in it
the whole motor path is more or less involved. Theoretically, primary lateral
sclerosis is a disease confined to the upper segment of the efferent tract, while
chronic anterior poliomyelitis involves the lower segment of the tract.
In connection with locomotor ataxia, general paralysis is considered on
account of their frequent association and of the possibility of their being
different expressions of one and the same morbid process ; and with progressive
(central) muscular atrophy, the other forms of muscular atrophy are consid-
ered as a matter of convenience. In other instances, too, diseases are arranged
in positions to which they might not be entitled, had a rigid classification of
system diseases been maintained.
n. DISEASES OF THE AFFERENT OR SENSORY
SYSTEM.
Locomotor Ataxia.
{Tabes Dorsalis; Posterior Spinal Sclerosis.)
Definition. — An affection characterized clinically by sensory disturbances,
incoordination, trophic changes, and involvement of the special senses, par-
ticularly the eyes. Anatomically there are found degenerations of the root
fibres of the dorsal columns of the cord, of the dorsal roots, and at times of
the spinal ganglia and peripheral nerves. Degenerations have been described
in the brain, particularly the cortex cerebri, in the ganglion cells of the cord,
and in the endogenous fibres of the dorsal columns.
Etiology. — It is a wide-spread disease, more frequent in cities than in the
country. The relative proportion may be judged from the fact that of 16,562
cases in the neurological dispensary of the Johns Hopkins Hospital, there were
201 cases of locomotor ataxia. Males are attacked more frequently than
females, the proportion being nearly 10 to 1. The disease, although uncom-
mon in the negro^, is seen in them more frequently than some authors state.
It is a disease of adult life, the great majority of cases occurring between the
thirtieth and fiftieth years. Occasionally cases are seen in young men, and
it may occur in children with hereditary s}-philis. Of special causes s}^hilis
is the most important. According to the figures of Erb, Fournier, Growers,
Starr, and others, in from 50 to 90 per cent of all cases there is a history
of this disease. In the Johns Hopkins Hospital the percentage, as found by
Thomas, was 63.1. Erb's recent figures are most striking — of 300 cases of
SYSTEM DISEASES. 887
tabes in private practice, 89 per cent had had syphilis. Moebius goes so far
as to say, " The longer I reflect upon it, the more firmly I believe that tabes
never originates without syphilis."
Excessive fatigue, overexertion, injury, exposure to cold and wet, and
sexual excesses are all assigned as causes. There are instances in which ;the
disease has closely followed severe exposure. James Stewart has noted that
the Ottawa lumbermen, who live a very hard life in the camps during the
winter months, are frequently the subjects of locomotor ataxia. Trauma has
been noted in a few cases. Alcoholic excess does not seem to predispose to the
disease. Among patients in the better classes of life I do not remember one
in which there had been a previous history of prolonged drunkenness. There
are now a good many cases on record of the existence of the disease in both
husband and wife, and a few where the children are also affected.
Morbid Anatomy and Pathology. — With a fuller knowledge of the anatomy
of the nervous system, our conception of tahes dorsalis has undergone many
changes. Posterior spinal sclerosis, although the most obvious gross change,
is now no longer, as in Eomberg's time, an adequate description of the con-
dition, for we know that the dorsal columns are composed of definite fibre
systems, and many attempts have been made to determine which of these are
affected in tabes, and where the primary lesion is situated. The dorsal fibres
are of two kinds, those with their cell bodies outside the cord in the spinal
ganglia, the so-called exogenous, or root fibres, and those which arise from
cells within the cord, the endogenous fibres. These two sets occupy fairly
well-determined regions of the dorsal columns and a study of early cases of
tabes has shown that it is the exogenous or root fibres that are first affected.
The fibres of the dorsal roots enter the cord in two divisions, an external and
an internal; the former is composed of fibres of small calibre, which, in the
cord, make up Lissauer's tract, and occupy the space between the apex of
the dorsal cornua and the periphery of the cord, and really do not form part
of the dorsal columns. They are short, soon entering the gray matter, and do
not seem to be affected, or only slightly so, in early cases (Mott, and Orr and
Eowe).
The larger fibres enter the cord by the internal division, just medial to the
cornua, in what is known as the root entry zone. Some enter the gray matter
of the spinal cord almost .directly and others after a longer course, while still
others run in the cord to the medulla, to end in the nuclei of the dorsal
columns. As the fibres of every spinal nerve enter the cord between the
dorsal cornua and the nerve fibres which have entered lower down, the fibres
from each root are successively pushed more and more toward the median
line, and so in the cervical cord the fasciculi of Goll are largely composed
of long fibres derived from the sacral and lumbar roots.
That it is the coarse dorsal root fibres which are first affected in tabes is
generally admitted, but there is much divergence of opinion as to the char-
acter and location of the Initial process.
Certain observers believe that the morbid agent, syphilis, for instance, acts
primarily on extra-nervous tissues, and that change in the root fibres is a
secondary degeneration. Nageotte calls attention to the frequency of a trans-
verse, interstitial neuritis of the dorsal roots just after they have left the
ganglia and are still surrounded by the dura, and he believes that it is this
888 DISEASES OF THE NERVOUS SYSTEM.
neuritis which is the primary lesion in tabes. Obersteiner and Eedlich have
laid great stress on the presence of an inflammation of the pia mater over
the dorsal aspect of the cord, which involves the root fibres as they pass
through. They point out that it is just here that the dorsal roots are most
vulnerable, for at this point — that is, while surrounded by the pia — they are
almost completely devoid of their myelin sheaths. Changes in the blood-
vessels of the cord, of the pia, and of the nerve roots have been described
in early tabes, and very lately Marie and Guillain have advanced the belief
that the changes in the cord are due to an affection (s}^hilis) of the posterior
lymphatic system which is confined to the dorsal columns of the cord, the pia
mater over them, and the dorsal roots. For them the changes in the nervous
system are only apparently radicular or systemic. Other observers regard the
primary change as an interstitial myelitis of the dorsal columns accompanied
by secondary changes.
In the belief of most authors, tabes is a systemic disease, at least it
starts as such; but here again there is much dispute as to just which part of
the sensory neurones is first affected. The peripheral nerves, the dorsal gan-
glia, the dorsal roots, and the intermeduUary portions of the neurones have
all been pointed out as starting places of the disease.
Flechsig, Trepinsky, and others hold that the disease is so truly systemic
that the degeneration in the dorsal columns follows closely the embryological
systems as determined by the time of their myelinization. Orr and Eowe, in
cases of general paresis, have described in detail what appear to be the earliest
tabetic changes in the dorsal columns, corresponding closely to the description
given by Mott in certain of his cases of tabo-paralysis.
With Marchi stain, degeneration of the root fibres in the root entry zone
was a constant finding. This change was radicular in the sense that it varied
in intensity with the different roots and was most marked in the sacral and
lumbar regions. The degeneration was not found in the dorsal roots, but began
within the cord just beyond where the root fibres had lost their neurolemma
and their myelin sheaths, and the authors believe that it is here that the fibres
are exposed to the action of poisons. They found no meningitis to account for
it. Degenerated fibres could be traced into the dorsal gray matter and among
the ganglion cells of the columns of Clarke. The long columns which ascend
the cord also degenerated.
In a study of more advanced cases, Mott found, in addition to the lesion de-
scribed above, degeneration of the dorsal roots and some alteration of the cells
in the spinal ganglia. The fibres distal to the ganglia were practically normal,
although at times the sensory fibres, at the periphery of a limb, showed de-
generation. Within the cord, the exogenous fibres were diseased as already
described, but he also found degeneration in the endogenous system of fi])res.
This was in advanced cases with marked ataxia. He thinks the process shows
both a systemic and a segmental election, and in this he is in agreement with a
number of other observers. In some cases the cells of Clarke's columns were
found diseased with secondary changes in the cerebellar tracts.
Mott found optic atrophy quite frequently, and believes that had he exam-
ined the optic nerves of all the cases changes would have been found in 60
per cent. The other cranial nerves, especially the fifth with its ganglion,
have been found degenerated.
SYSTEM DISEASES. 889
The disease occasionally spreads beyond the sensory system in the cord,
and in advanced cases the cells in the ventral horns may be degenerated in
association with muscular atrophy. In his asylum cases, Mott very generally
found more or less marked changes in the pyramidal fibres; these he believed
to be evidence of changes in the cerebral cortex. Degeneration of the cortex
was to be expected in his cases of tabo-paralysis, but even in cases where the
mental symptoms were absent, or very mild, similar though slight changes
have been described, just as in general paralysis, without marked tabetic
symptoms, there may be degeneration of the dorsal columns. The close asso-
ciation, or even identity, of tabes and general paralysis will be considered
later.
Symptoms. — These are best considered under three stages — the incipient
stage, the ataxic stage, and the paralytic stage.
The Incipient Stage. — This is sometim'es called the pre-ataxic stage.
The manner in which tabes makes its onset differs very widely in the different
cases, and mistakes in diagnosis are often made early in the disease. The fol-
lowing are the most characteristic initial symptoms :
Pains, usually of a sharp stabbing character; hence the term lightning
pains. They last for only a second or two and are most common in the legs
or about the trunk, and tend to follow dorsal root areas. They dart from place
to place. At times they are associated with a hot burning feeling and often
leave the affected area painful to pressure, and occasionally herpes may fol-
low. The intensity of the pain varies from a sore, burning feeling of the skin
to a pain so intense that were it not for its momentary duration it would
exceed human endurance. They occur at irregular intervals, and are prone
to follow excesses or to come on when health is impaired. When typical, these
pains are practically pathognomonic of the condition. (See Sir William
Gowers' clinical lecture.) The gastric crises and other crises may occur,
Parsesthesia may also be among the first symptoms, — numbness of the feet,
tingling, etc., and at times a sense of constriction about the body.
Ocular Symptoms. — (a) Optic atrophy. This occurs in about 10 per cent
of the cases, and is often an early and even the first symptom. There is a
gradual loss of vision, which in a large majority of cases leads to total blind-
ness, (&) Ptosis, which may be double or single, (c) Paralysis of the exter-
nal muscles of the eye. This may be of a single muscle or occasionally of all
the muscles of the eye. The paralysis is often transient, the patient merely
complaining that he saw double for a certain period, (d) Argyll Eobertson
pupil, in which there is loss of the iris reflex to light but contraction during
accommodation. The pupils are often very small — spinal myosis.
Bladder Symptoms. — The first warning of the disease which the patient
has may be a certain difficulty in emptying the bladder. Incontinence of
urine occurs only at a later stage of the disease. Decrease in sexual desire
and power may also be an early symptom.
Trophic Disturbances. — These usually occur later in the disease, but at
times they are very early symptoms and it is not very infrequent to have one's
attention called to the trouble by the presence of a perforating ulcer or of a
characteristic Charcot's joint.
Loss of the Deep Reflexes. — This early and most important symptom may
occur years before the development of ataxia. Even alone it is of great mo-
S8
890 DISEASES OF THE NERVOUS SYSTEM.
ment, since it is very rare to meet with individuals in whom the knee and
ankle jerks are normally absent. The combination of loss of either of these
with one or more of the symptoms mentioned above, especially with the light-
ning pains and ptosis or Argyll Robertson pupil, is practically diagnostic.
These reflexes gradually decrease, and one may be lost before the other, or
disappear first in one leg.
These are the most common symptoms of the initial stage of tabes and
may persist for years without the development of incoordination. The patient
may look well and feel well, and be troubled only by occasional attacks of
lightning pains or of one of the other subjective symptoms. Moebius goes
so far as to state that the typical Argyll Robertson pupil means either tabes
or general paralysis, and that paralysis of the external muscles of the eye
developing in adults is of almost equal importance, especially if it develops
painlessly.
The time between the syphilitic infection and the occurrence of the first
symptoms of locomotor ataxia varies within wide limits. About one-half the
cases occur between the sixth and fifteenth year, but many begin even later
than this.
The disease may never progress beyond this stage, and when optic atrophy
develops early and leads to blindness, ataxia rarely, if ever, supervenes, but the
mental symptoms of paresis not infrequently follow, a sequence which must
be kept in mind. There is a sort of antagonism between the ocular symptoms
and the progress of the ataxia. Charcot laid considerable stress upon this, and
both Dejerine and Spiller have since emphasized the point.
Ataxic Stage. — Motor Symptoms. — The ataxia is believed to be due to
a disturbance or loss of the afferent impulses from the muscles, joints, and
deep tissues, and a disturbance of the muscle sense itself can usually be demon-
strated. It develops gradually. One of the first indications to the patient is
inability to get about readily in the dark or to maintain his equilibrium when
washing his face with the eyes shut. When the patient stands with the feet
together and the eyes closed, he sways and has difficulty in maintaining his
position (Romberg's symptom), and he may be quite unable to stand on one
leg. He does not start off promptly at the word of command. On turning
quickly he is apt to fall. He descends stairs with more difficulty than he
ascends them. Gradually the characteristic ataxic gait develops. The patient,
as a rule, walks with a stick, the eyes are directed to the ground, the body
is thrown forward, and the legs are wide apart. In walking, the leg is thrown
out violently, the foot is raised too high and is brought down in a stamping
manner with the heel first, or the whole sole comes in contact with the ground.
Ultimately the patient may be unable to walk without the assistance of two
canes. This gait is very characteristic, and unlike that seen in any other dis-
ease. The incoordination is not only in walking, but in the performance of
other movements. If the patient is asked, when in the recumbent posture, to
touch one knee with the other foot, the irregularity of the movement is very
evident. Incoordination of the arms is less common, but usually develops in
some grade. It may in rare instances exist before the incoordination of the
legs. It may be tested by asking the patient to close his eyes and to touch the
tip of the nose or the tip of the ear with the finger, or with the arms thrust
out to bring the tips of the fingers together. The incoordination may early
SYSTEM DISEASES. _ 891
be noticed by a difficulty which the patient experiences in buttoning liis collar
or in performing one of the ordinary routine acts of dressing.
One of the most striking features of the disease is that with marked inco-
ordination there is but little loss of muscular power. The grip of the hands
may be strong and firm, the power of the legs, tested by trying to flex them,
may be unimpaired, and their nutrition, except toward the close, may be
unaffected.
There is a remarkable muscular relaxation which enables the joints to
be placed in positions of hyperextension and hyperflexion. It gives some-
times a marked backward curve to the legs. Frankel, who calls the condition
hypotonia, says it may be an early symptom.
Sensory Symptoms. — The lightning pains may persist. They vary greatly
in different cases. Some patients are rendered miserable by the frequent occur-
rence of the attacks; others escape altogether. In addition, common symp-
toms are tingling, pins and needles, particularly in the feet, and areas of
hypersesthesia or of angesthesia. The patient m,ay complain of a change in
the sensation in the soles of the feet, as if cotton was interposed between the
floor and the skin. Sensory disturbances occur less frequently in the hands.
Objective sensory disturbances can usually be demonstrated, and indeed almost
every variety of sensory disturbance has been described. They have been
carefully studied in America by Knapp and by Patrick, and in Europe by
many observers. Bands about the chest of a moderate grade of anaesthesia are
not uncommon; they are apt to follow the distribution of spinal segments.
The most marked disturbances are usually found on the legs. Eetardation of
the sense of pain is common, and a pin-prick on the foot is first felt as a simple
tactile impression, and the sense of pain is not perceived for a second or two
or may be delayed for as much as ten seconds. The pain felt may persist.
A curious phenomenon is the loss of the power of localizing the pain. For
instance, if the patient is pricked on one limb he may say that he feels it
on the other (allocheiria), or a pin-prick on the foot may be felt on both feet.
The muscular sense which is usually affected early, becomes much impaired
and the patient no longer recognizes the position in which his limbs are placed.
This may be present in the pre-ataxic stage.
Reflexes. — As mentioned, the loss of the knee and ankle jerks is one of the
earliest symptoms of the disease. Occasionally a case is found in which they
are retained. The skin reflexes may at first be increased, but later are usually
involved with the deep reflexes.
Special Senses. — The eye symptoms noted above may be present, but, as
mentioned, ataxia is rare with atrophy of the optic nerve.
Deafness may develop, due to lesion of the auditory nerve. There may also
be attacks of vertigo. Olfactory symptoms are rare.
Visceral Symptoms. — Among the most remarkable sensory disturbances
are the tabetic crises, severe paroxysms of pain referred to various viscera;
thus laryngeal, gastric, nephric, rectal, urethral, and clitoral crises have been
described. The most common are the gastric and laryngeal. In the former
there are intense pains in the stomach, vomiting, and a secretion of hyperacid
gastric juice. The attack may last for several days or even longer. There
may be severe pain without any vomiting. The attacks are of variable intensity
and usually require morphia. Paroxysms of rectal pain and tenesmus are
892 DISEASES OF THE NERVOUS SYSTEM.
described. They have not been common in my experience. Laryngeal crises
also are rare. There may be true spasm with dyspnoea and noisy inspiration.
In one instance at least the patient has died in the attack. There are also
nasal crises, associated with sneezing fits.
The sphincters are frequently involved. Early in the disease there may
be a retardation or hesitancy in making water. Later there is retention, and
cystitis may occur. L'nless great care is taken the inflammation may extend
to the kidneys. Constipation is extremely common. Late in the disease the
sphincter ani is weakened. The sexual power is usually lost in the ataxic stage.
Trophic Changes. — Skin rashes may develop in the course of the light-
ning pains, such as herpes, oedema, or local sweating. Alteration in the nails
may occur. A perforating ulcer may develop on the foot, usually beneath
the great toe. A perforating buccal ulcer has also been described. Onychia
may prove very troublesome.
Arthropathies (Charcot's Joints). — Anatomically there are: (1) enlarge-
ment of the capsule with thickening of the synovial membranes and increase
in the fluids; (2) slight enlargement of the ends of the bones, with slight
exostoses; (3) a dull velvety appearance of the cartilages, with atrophy in
places {Y. E. Henderson). The knees are most frequently involved. The
spine is affected in rare instances. Eecurring trauma is an important element
in the causation, but trophic disturbances have a strong influence in the eti-
ology. A striking feature is the absence of pain. Suppuration may occur,
also spontaneous fractures. Among other trophic disturbances may be men-
tioned atrophy of the muscles, which is usually a late manifestation, but may
be localized and associated with neuritis. In any very large collection of cases
many instances of atrophy are found, due either to involvement of the ventral
horns or to peripheral neuritis.
Cerehral Symptoms. — Hemiplegia may develop at any stage of the disease,
more commonly when it is well advanced. It may be due to hgemorrhagic
softening in consequence of disease of the vessels or to progressive cortical
changes. Hemiansesthesia is sometimes present. Very rarely the hemiplegia
is due to coarse syphilitic disease.
Dementia paralytica frequently exists with tabes; indeed we have come
to regard these two diseases as simply different localizations of the same mor-
bid process. In other instances melancholia, dementia, or paranoia occur.
Paralytic Stage. — After persisting for an indefinite number of years
the patient gradually loses the power of walking and becomes bedridden or
paralyzed. In this condition he is very likely to be carried off by some inter-
current affection, such as pyelo-nephritis, pneumonia, or tuberculosis.
The Course of the Disease. — A patient may remain in the pre-ataxic stage
for an indefinite period; and the loss of knee-jerk and the gray atrophy of
the optic nerves may be the sole indication of the true nature of the disease.
In such cases incoordination rarely develops. In a majority of cases the
progress is slow, and after six or eight j^ears, sometimes less, the ataxia is
well developed. The sjonptoms may vary a good deal; thus the pains, which
may have been excessive at first, often lessen. The disease may remain station-
ary for years; then exacerbations occur and it makes rapid progress. Occa-
sionally the process seems to be arrested. There are instances of what may
be called acute ataxia, in which, within a vear or even less, the incoordination
SYSTEM DISEASES. 893
is marked, and the paralytic stage ma}^ develop within a few months. The
disease itself rarely causes death, and after becoming bedridden the patient
may live for fifteen or twenty years.
Diagnosis. — In the initial stage the lightning pains are almost distinctive,
and when combined with any of the other signs are quite so. The associatipn
of progressive atrophy of the optic nerves with loss of knee-jerk is also char-
acteristic. The early ocular palsies are of the greatest importance. A squint,
ptosis, or the Argyll Eobertson pupil may be the first symptom, and may exist
with the loss only of the knee-jerk. Loss of the knee-jerk alone, however,
does occasionally occur in healthy individuals. A history of preceding syphilis
lends added weight to the symptoms, and its presence or absence may be of
the utmost importance in determining the diagnosis. If the possibility of
syphilitic infection can be excluded, a circumstance but too rarely met with,
only the most unequivocal combination of symptoms can justify the diagnosis
of locomotor ataxia. Cytodiagnosis may be a help in doubtful cases (see
General Paresis), and Wassermann's reaction may be present.
The diseases most likely to be confounded with locotomor ataxia are : ( 1 )
Peeipheral Neuritis. — The steppage gait of arsenical, alcoholic, or diabetic
paralysis is quite unlike that of locomotor ataxia. In these forms there is a
paralysis of the feet, and the leg is lifted high in order that the toes may clear
the floor. The use of the word ataxia in this connection should no longer be
continued. In the rare cases in which the muscle sense nerves are particularly
affected and in which there is true ataxia, the absence of the lightning pains
and eye symptoms and the history will suffice in a majority of cases to make
the diagnosis clear. In diphtheritic paralysis the early loss of the knee-jerk
and the associated eye symptoms may suggest tabes, but the history, the exist-
ence of paralysis of the throat, and the absence of pains render a diagnosis
easy.
(2) Ataxic Paraplegia. — Marked incoordination with spastic paralysis
is characteristic of the condition which Growers has termed ataxic paraplegia.
In a majority of the cases this affection is distinguished also by the absence
of pains and of eye symptoms, but it may be a manifestation of the cord lesions
in tabo-paralysis.
(3) Cerebral Disease. — In diseases of the brain involving the afferent
tracts ataxia is at times a prominent symptom. It is usually unilateral or
limited to one limb; this, with the history and the associated symptoms,
excludes tabes.
(4) Cerebellar Disease. — The cerebellar incoordination has only a
superficial resemblance to that of locomotor ataxia, and is more a disturbance
of equilibrium than a true ataxia; the knee-jerk is usually present, there are
no lightning pains, no sensory disturbances; while, on the other hand, there
are headache, optic neuritis, and vomiting.
(5) Some acute affections involving the dorsal columns of the cord may
be followed by incoordination and resemble tabes very closely. In a case under
my care, the gait was characteristic and Romberg's symptom was present.
The knee-jerk, however, was retained and there were no ocular symptoms.
The condition had developed within three or four months, and there was a
well-marked history of syphilis. Under large doses of iodide of potassium
the ataxia and other symptoms completely disappeared.
894 DISEASES OF THE NERVOUS SYSTEM.
(6) General Paresis. — Even though these two diseases are so uearly
allied and often associated, it is of very great practical importance to deter-
mine, when possible, whether the type is to be spinal or cerebral, for, in the
great majorit}^ of cases, when this is established, it does not change. The
difficulty arises in the premonitory stage, when ocular changes and abnor-
malities of sensation and the deep reflexes may be the only symptoms. At
this stage any alteration in the mental characteristics is of the utmost sig-
nificance. (See General Paresis.) Loss of the deep reflexes and lightning
pains speak for tabes; active reflexes, with ocular changes, especially ojjtic
atrophy, are suggestive of paresis,
(7) Visceral crises and >7EItralgic symptoms may lead to error, and in
middle-aged men with severe, recurring attacks of gastralgia it is always
well to bear in mind the possibility of tabes, and to make a careful examina-
tion of the eyes and of the knee-jerk.
Prognosis. — Complete recovery can not be expected, but arrest of the
process is not uncommon and a marked amelioration of the symptoms is
frequent. Optic-nerve atrophy, one of the most serious events in the disease,
has this hopeful aspect — that incoordination rarely follows and the progress
of the spinal sjTnptoms may be arrested. On the other hand, mental symptoms
are nxore likely to follow. The optic atrophy itself is occasionally checked.
On the whole, the prognosis in tabes is bad. The experience of such men as
Weir Mitchell, Charcot, and Gowers is distinctly opposed to the belief that
locomotor ataxia is ever completely cured. Xo such ease has come under
my personal observation.
Treatment. — To arrest the progress and to relieve, if possible, the S3Tnp-
toms are the objects which the practitioner should have in view. A quiet, well-
regulated method of life is essential. It is not well, as a rule, for a patient to
give up his occupation so long as he is able to keep about and perform ordinary
work, provided there is no evident mental change. I know tabetics who have
for years conducted large businesses, and there have been several notable in-
stances in our profession of men who have risen to distinction in spite of the
existence of this disease. Excesses of all sorts, more particularly in hacclio
et venere, should be carefully avoided. A man in the pre-ataxic stage should
not marry.
Care should be taken in the diet, particularly if gastric crises have oc-
curred. To secure arrest of the disease many remedies have been employed.
Although syphilis plays such an important role in the etiolog}^, it is univer-
sally acknowledged that neither mercury nor the iodide of potassium have any-
thing like the same influence over the tabetic lesions that they have over the
ordinary syphilitic processes. However, when the syphilis is comparatively
recent, when symptoms develop within two years of the primary infection,
the disease may be arrested by mercury and iodide of potassium. The French
authors have recently spoken mnch more hopefully of the benefit of anti-
syphilitic treatment in early cases of tabes, and it is well to give the patient
the benefit of at least one thorough course of mercurial inunctions and iodide
of potassium. Of remedies which may be tried and are believed by some
writers to retard the progress, the following are recommended : Arsenic in
full doses, nitrate of silver in quarter-grain doses, Calabar bean, ergot, and
the preparations of gold.
SYSTEM DISEASES. 895
For the pains, complete rest in bed, as advised by Weir Mitchell, and
coimter-irritation to the spine (either blisters or the thermo -cautery) may
be employed. The severe spells which come on particularly after excesses of
any kind are often promptly relieved by a hot bath or by a Turkish bath.
For the severe recurring attacks of lightning pains spinal cocainization may
be tried. In an instance reported to me by Dr. George Goodfellow, of San
Francisco, excellent results followed. A prolonged course of nitrate of silver
seems in some cases to allay the pains and lessen the liability to the attacks.
I have never seen ill effects from its use in spinal sclerosis. Antipyrin and
antifebrin may be employed, and occasionally do good, but their analgesic
powers in this disease have been greatly overrated. Cannabis indica is some-
times useful. In the severe paroxysms of pain hypodermics of morphia or of
cocaine must be used. The use of morphia should be postponed as long as
possible. Electricity is of very little benefit. For the severe attacks of gas-
tralgia, morphia is also required. The laryngeal crises are rarely dangerous.
x\n application of cocaine may be made during the spasm, or a few whiffs of
chloroform may be given, or nitrate of amyl. In all cases of tabes with in-
creased arterial tension the prolonged use of nitroglycerin, given in increasing
doses until the physiological effect is produced, is of great service in allaying
the neuralgic pains and diminishing the frequency of the crises. Its use must
be guarded when there is aortic insufficiency. The special indication is in-
creased tension. The bladder symptom^ demand constant care. When the
organ can not be perfectly emptied the catheter should be used, and the patient
may be taught its use and how to keep it thoroughly sterilized.
Frenkel's method of re-education often helps the patient to regain to a
considerable extent the control of the voluntary movements which he has
lost. (English translation of his work by P. Blakiston's Son & Co.) By this
method the patient is first taught, by repeated systematic efforts, to perform
simple movements ; from this he goes to more and more complex movements.
The treatment should be directed and supervised by a trained teacher, as the
result depends upon the skill of the teacher quite as much as upon the perse-
verance of the patient.
General Paralysis of the Insane and Tabo-paralysis
(Dementia Paralytica; General Paresis).
As has been said in the last section, the belief in the essential identity of
general paralysis and tabes has gained more and more ground and has much in
its favor. Mott says : " I maintain that etiologically and pathogenetically there
is one tales which may begin in the brain (especially in certain regions), or in
the spinal cord in certain regions, or in the peripheral nervous structures con-
nected with vision, or in nervous structures connected with the viscera,
constituting, therefore, different types, any of which m^ay be present or be
associated with one or all of the others.^' Fournier has taken practically the
same view and describes them together under the heading Les Affections Para-
sypliilitiques. Moebius, Shaffer, and others are equally positive in their
statements.
It is undoubted that most cases of tabes run their course with practically
no mental symptoms, and that cases of general paralysis may never present
896 DISEASES OF THE NERVOUS SYSTEM.
symptoms that suggest tabes. For practical purposes we are forced to keep
the distinction clearly in mind, and for this reason it seems best, at least for
the present, to consider them separately.
There is, however, a group of cases in which the symptoms of the two dis-
eases are associated in every combination. The name " tabo-paralysis " has
been given to these cases.
(a) General Paralysis.
Definition. — A chronic, progressive disease of the brain and its meninges,
associated with psychical and motor disturbances, finally leading to dementia
and paralysis.
Etiology. — As in tabes, the most important individual factor is syphilis,
which is antecedent in both conditions in from 70 to 90 per cent of all cases.
Males are affected much more frequently than females. It occurs chiefly
between the ages of thirty and fifty-five, although it may begin in childhood
as the result of congenital syphilis. An overwhelming majority of the cases
are in married people, and not infrequently both husband and wife are affected,
or one has paresis and the other tabes. Statistics show that it is more common
in the lower classes of society, but in America in general medical practice the
disease is certainly more common in the well-to-do classes. Heredity is a
more important factor here than in tabes, although its influence is not great.
An important predisposing cause is " a life absorbed in ambitious projects
with all its strongest mental efforts, its long-sustained anxieties, deferred
hopes, and straining expectation^' (Mickle). The habits of life so frequently
seen in active business men in our large cities, and well expressed by the
phrase " burning the candle at both ends," strongly predispose to the disease.
Morbid Anatomy. — The dura is often thickened, and its inner surface
may show the various forms of hypertrophic pachymeningitis. The pia is
cloudy, thickened, and adherent to the cortex. The cerebro-spinal fluid is
increased in the meningeal spaces, especially in the meshes of the pia, and at
times to such an extent as to resemble cysts. The brain is small, and weighs
less than normal. The convolutions are atrophied, especially in the anterior
and middle lobes. In acute cases the brain may be swollen, hyperffimic, and
oedematous. The brain cortex is usually red, and, except in advanced cases,
it may not be atrophied, the atrophy of the hemispheres being at the expense
of the white matter. The lateral ventricles are dilated to compensate for the
atrophy of the brain, and the ependyma may be granular. The fourth ven-
tricle is more constantly dilated, with granulations of its floor covering the
calamus scriptorius, a condition seldom seen in any other affection.
Histologically there is atrophy of the nerve fibres, especially the tangental
and supra-radial, degeneration of the nerve cells of the cortex, and a great
overgrowth of the neuroglia, with the presence of numerous giant spider cells.
In the dilated adventitial spaces of the blood-vessels there is a great accumu-
lation of cells — plasma cells with a few lymphocytes and an occasional mast
cell. In the tissue itself are found the curious rod-shaped structures, which
are derived from the vessel walls. Compound granular corpuscles are also
found near necrotic areas. There is often a very great increase in the small
blood-vessels, and various kinds of alterations of the vessel walls have been
described. The improved methods of staining the neuro-fibrils (Cajal and
SYSTEM DISEASES. 897
Pielschowsky) are beginning to tlirow light upon the essential cellular
changes.
The disease process is diffuse, and affects practically all parts of the brain,
but its intensity varies greatly, even in adjoining areas. As a rule the cortex
of the frontal and central convolutions and the gray matter about the ven-
tricles are most affected.
In many cases changes are present in the spinal cord and peripheral nerves.
There are the typical tabetic changes described in the preceding section. There
may be degeneration of the pyramidal systems of fibres secondary to the cor-
tical changes. Most commonly there is a combination of these two processes.
Foci of haemorrhages, and softening dependent upon coarse vascular changes,
are not infrequently found, but are not typical of the disease.
There are various views as to the nature of the changes. The vascular
theory is that from an inflammatory process starting in the sheaths of the
arterioles there is a diffuse parenchymatous degeneration with atrophic changes
in the nerve cells and neuroglia. The most generally accepted view is that
some unknown toxin causes degeneration in the nervous tissues with secondary
changes in the neuroglia and vascular systems.
Symptoms. — Pkodromal Stage. — This is of variable duration, and is char-
acterized by a general mental state which finds expression in symptoms trivial
in themselves but important in connection with others. Irritability, inatten-
tion to business amounting sometimes to indifference or apathy, and some-
times a change in character, marked by acts which may astonish the friends
and relatives, may be the first indications. There may be unaccountable
fatigue after moderate physical or mental exertion. Instead of apathy or indif-
ference there may be an extraordinary degree of physical and mental restless-
ness. The patient is continually planning and scheming, or may launch into
extravagances and speculation of the wildest character. A common feature
at this period is the display of an unbounded egoism. He boasts of his per-
sonal attainments, his property, his position in life, or of his wife and chil-
dren. Following these features are important indications of moral perversion,
manifested in offences against decency or the law, many of which acts have
about them a suspicious effrontery. Forgetfulness is common, and may be
shown in inattention to business details and in the minor courtesies of life.
At this period there may be no motor phenomena. The onset of the disease is
usually insidious, although cases are reported in which epileptiform or apo-
plectiform seizures were the first symptoms. Among the early motor features
are tremor of the tongue and lips in speaking, slowness of speech and hesi-
tancy. Inequality of the pupils, the Argyll Robertson pupil, optic atrophy,
and changes in the deep refiexes may precede the occurrence of mental symp-
toms for years.
Second Stage. — This is characterized in brief by mental exaltation or
excitement and a progress in the motor symptoms. " The intensity of the
excitement is often extreme, acute maniacal states are frequent; incessant
restlessness, obstinate sleeplessness, noisy, boisterous excitement, and blind,
uncalculating violence especially characterize such states" (Lewis). It is at
this stage that the delusion of grandeur becomes marked and the patient
believes himself to be possessed of countless millions or to have reached the
most exalted sphere possible in profession or occupation. This expansive
DISEASES OF THE NERVOUS SYSTEM.
delirium, as it is called, is, however, not characteristic, as was formerly sup-
posed, of paralytic dementia. Besides, it does not always occur, but in its
stead there may be marked melancholia or hypochondriasis, or, in other in-
stances, alternate attacks of delirium and depression.
The facies has a peculiar stolidity, and in speaking there is marked tremu-
lousness of the lips and facial muscles. The tongue is also tremulous, and may
be protruded with difficulty. The speech is slow, interrupted, and blurred.
Writing becomes difficult on account of unsteadiness of the hand. Letters,
syllables, and words may be omitted. The subject matter of the patient's
letters gives valuable indications of the mental condition. In many instances
the pupils are unequal, irregular, sluggish, sometimes large. Important
symptoms in this stage are apoplectiform seizures and paralysis. There may
be slight sjTicopal attacks in which the patient turns pale and may fall. Some
of these are petit mal. In the true apoplectiform seizure the patient falls sud-
denly, becomes unconscious, the limbs are relaxed, the face is flushed, the
breathing stertorous, the temperature increased, and death may occur. Epi-
leptic seizures are more common than the apoplectiform. There may be
a definite aura. The attack usually begins on one side and may not spread.
There may be twitchings either in the facial or brachial muscles. Typical
Jacksonian epilepsy may occur. In a case which died recently under my
care, these seizures were among the early symptoms and the disease was
regarded as cerebral syphilis. Eecurring attacks of aphasia are not un-
common, and paralysis, either monoplegic or hemiplegic, may follow these
epileptic seizures, or may come on with great suddenness and be transient.
In this stage the gait becomes impaired, the patient trips readily, has diffi-
culty in going up or down stairs, and the walk may be spastic or occa-
sionally tabetic. This paresis may be progressive. The deep reflexes are
usually increased, but may be lost. Bladder or rectal symptoms gradually
develop. The patient becomes helpless, bedridden, and completely demented,
and unless care is taken may suffer from bedsores. Death occurs from exhaus-
tion or from some intercurrent affection. The spinal-cord features of dementia
paralytica may come on with or precede the mental troubles. There are cases
in which one is in doubt for a time whether the symptoms indicate tal^es or
dementia paralytica, and it is well to bear in mind that every feature of pre-
ataxic tabes may exist in the early stage of general paresis.
(&) Taho-paralysis.
Emphasis has been laid on the probable identity of the processes underlying
tabes and dementia paralytica, the spinal cord in the first case receiving the
full force of the attack, and the brain in the second. It has been thought that
stress is the factor which determines the location of the process, and that men
whose occupations require much bodily exercise would be apt to have tabes,
while those whose activities are largely mental would suffer from paresis.
Usually when the cord symptoms are pronounced the symptoms from the brain
remain in abeyance, and the reverse is also true. There are exceptions to
this, and cases of well marked tabes may later show the typical symptoms
of paresis, but even then the ataxia, if it is not of too high a grade, often
improves.
SYSTEM DISEASES. 899
Optic atrophy, when it occurs in the pre-ataxic stage of tabes, usually indi-
cates that the ataxia will never be pronounced, but unfortunately it is fre-
quently followed by the occurrence of mental symptoms. Mott believes that
about 50 per cent of his asylum cases of tabo-paralysis had had preceding optic
atrophy. Its occurrence is therefore of grave significance. The mental symp-
toms may be delayed for many years.
The symptom complex of tabo-paralysis is made up of a combination of
the symptoms of the two conditions, and varies greatly. It may begin as tabes
with lightning pains, bladder symptoms, Argyll Eobertson pupil, loss of the
deep reflexes, etc., to have the mental symptoms added later ; or, on the other
hand, cord symptoms may come on after the patient has shown marked
mental changes. In a number of cases the symptoms are from the first so
combined that the name tabo-paralysis is at once applicable. Absent knee-
jerks, ocular palsies, or pupillary symptoms may precede the breakdown for
many years, but none of them have so grave a significance in regard to the
mental state as has optic atrophy. Other types of alienation may interrupt
the course of tabes, and the mistake must not be made of regarding them
all as general paralysis. In such instances the mind may become clear and
remain so to the end.
Diagnosis. — The recognition of general paralysis in the earliest stage is
extremely difficult, as it is often impossible to decide that the slight altera-
tion in conduct is anything more than one of the moods or phases to which
most men are at times subject. The following description by Folsom is an
admirable presentation of the diagnostic characters of the early stage of the
disease : " It should arouse suspicion if, for instance, a strong, healthy man,
in or near the prime of life, distinctly not of the ' nervous,' neurotic, or neu-
rasthenic type, shows some loss of interest in his affairs or impaired faculty of
attending to them; if he becomes varyingly absent-minded, heedless, indif-
ferent, negligent, apathetic, inconsiderate, and, although able to follow his
routine duties, his ability to take up new work is, no matter how little,
diminished; if he can less well command mental attention and concentration,
conception, perception, reflection, judgment; if there is an unwonted lack of
initiative, and if exertion causes unwonted mental and physical fatigue; if the
emotions are intensified and easily change, or are excited readily from trifling
causes ; if the sexual instinct is not reasonably controlled ; if the finer feelings
are even slightly blunted; if the person in question regards with a placid
apathy his own acts of indifference and irritability and their consequences,
and especially if at times he sees himself in his true light and suddenly fails
again to do so; if any symptoms of cerebral vaso-motor disturbances are
noticed, however vague or variable,"
There are cases of cerebral syphilis which closely simulate dementia para-
lytica. The mode of onset is important, particularly since paralytic symp-
toms are usually early in syphilis. The affection of the speech and tongue
is not present. Epileptic seizures are more common and more liable to be
cortical or Jacksonian in character. The expansive delirium is rare. While
symptoms of general paresis are not common in connection with the develop-
ment of gummata or definite gummatous meningitis, there are, on the other
hand, instances of paresis following closely upon the syphilitic infection.
Post mortem in such cases there may be nothing more than a general arterio-
900 DISEASES OF THE NERVOUS SYSTEM.
sclerosis and diffuse meningo-enceplialitis, which may present nothing dis-
tinctive, but the lesions, nevertheless, may be caused by the syphilitic virus.
Cases also occur in which typical syphilitic lesions are combined with the ordi-
nar}' lesions of dementia paralytica. There are certain forms of lead enceph-
alopathy which resemble general paresis, and, considering the association of
plumbism with arterio-sclerosis, it is not unlikely that the anatomical sub-
stratum of the disease may result from this poison. Tumor may sometimes
simulate progressive paresis, but in the former the signs of general increase
of the intracranial pressure are usually present. The Wassermann reaction
(see SA'iDhilis) is present in a majority of cases.
Cytodiagnosis. — The study of the cellular elements suspended in the cere-
bro-spinal fluid, first instituted by Widal and Eavaut (1900) in cases of de-
mentia paralytica, has come to be an important diagnostic measure, particu-
larly in tabes and paresis. In both of these affections spinal hmiphocytosis is
the rule and is usually associated with a marked albumin reaction — the nor-
mal fluid containing no albumiu, or at most minute traces, and a negligible
number of formed elements. It is simply the expression of a subacute or
clironic inflammatory process, just as polymorphonuclear leukocytosis is char-
acteristic of an acute process. It is, however, first and foremost the syphilitic
triad — tabes, paresis, and cerebro-spinal lues — which is suggested by lympho-
c}i;osis in the spinal fluid. Positive reactions, etiological and chemical, are
among the earliest somatic s}Tnptoms, and may therefore clear up obscure
cases of tabes and paresis, just at the time when diagnosis is most difficult.
Prognosis. — The disease rarely ends in recovery. As a rule the progress
is si owl}' downward and the case terminates in a few years, although it is
occasionally prolonged ten or fifteen years.
Treatment. — The only hope of permanent relief is in the cases following
sj^philis, which should be placed upon large doses of iodide of potassium, and
given a mercurial course. Careful nursing and the orderly life of an asylum
are the only measures necessary in a great majority of the cases. For sleep-
lessness and the epileptic seizures bromides may be used. Prolonged remis-
sions, which are not uncommon, are often erroneously attributed to the action
of remedies. Active treatment in the early stage by wet-packs, cold to the
head, and systematic massage have been followed by temporary improvement.
Herpes Zostee
{Zona; Acute HcBmorrliagic Inflammation of the Dorsal Root Ganglia).
Zoster is an acute specific disease of the nervous system with a localization
in the ganglia of the posterior roots (Head and Campbell). There are hsemor-
rhages and inflammatory foci, with destruction of certain of the ganglion cells,
leading to degeneration of their axis-cylinder processes. "W. T. Howard has
shown, even in the herpes facialis such as accompanies pneumonia, that hsemor-
rhagic lesions akin to those of true zoster are demonstrable in the Gasserian
ganglion. The two conditions, however, are etiologically quite distinct.
Chauffard reports cases which indicate an extension of the process from
the posterior ganglia to the neighboring meninges. There may be pains down
the spine, girdle pains, and exaggerated knee jerks with marked lymphocytosis.
Herpes auricularis is associated with lesions in the otic ganglion (Ramsay
SYSTEM DISEASES. 901
Hunt), and this form may be complicated with a transient facial paralysis and
sometimes with severe auditory symptoms.
In zoster there is often a prodromal period, in which the patient feels ill,
has pain, and the rash comes out on the third or fourth day. The character-
istic outcrop of vesicles has a segmental distribution, one or more of the
adjoining skin-fields being affected, almost invariably limited to one side of
the body. With involvement of cervical, lumbar, or sacral ganglia the zonal
or girdle form of the vesicular outcrop, from which the disease gets its name,
is naturally lost owing to the distortion of the skin-fields from the growth
of the limbs. It is present in its typical form only when the thoracic ganglia
are aifected. The eruption is most abundant in patches, corresponding to the
anterior, lateral, and posterior divisions of the nerves, and in severe cases
the vesicles over these areas may become confluent and lead to ulcerations.
True zoster not infrequently affects one or more of the divisions of the Gas-
serian ganglion.
Individuals rarely suffer from more than one attack of zoster. The disease
is much more common in children, in whom it may be accompanied by slight,
if any, discomfort, and leave no traces. Severe cases in elderly people, how-
ever, are often followed by the most intractable forms of neuralgia.
III. DISEASES OF THE EFFERENT OR MOTOR TRACT.
A. OF WHOLE TRACT.
1. Progressive (Central) Muscular Atrophy
(Poliomyelitis Anterior Chronica; Amyotrophic Lateral Sclerosis; Progressive
Bulbar Paralysis).
Definition. — A disease characterized by a chronic degeneration of the motor
tract. The whole tract is usually involved, but at times the degeneration is
limited to the lower segment. Associated with it is a progressive atrophy of
the muscles, combined with more or less spastic rigidity. Three affections,
as a rule described apart, belong together in this category: (a) Progressive
muscular atrophy of spinal origin; (&) amyotrophic lateral sclerosis; and (c)
progressive bulbar paralysis. A slow atrophic change in the motor neurones is
the anatomical basis, and the disease is one of the whole motor path, involving,
in many cases, the cortical, bulbar, and spinal centres. There may be simple
muscular atrophy with little or no spasm, or progressive wasting with marked
spasm' and great increase in the reflexes. In others, there are added symptoms
of involvement of the motor nuclei in the medulla — a glosso-labio-laryngeal
paralysis; while in others, again, with atrophy (especially of the arms), a
spastic condition of the legs and bulbar phenomena, tremors develop and signs
of cortical lesion. These various stages may be traced in the same case.
For convenience, bulbar paralysis will be considered separately, and I shall
here take up together progressive muscular atrophy and amyotrophic lateral
sclerosis.
The disease is known as the Aran-Duchenne type of progressive muscular
atrophy and as Cruveilhier's palsy, after the French physicians who early de-
902 DISEASES OF THE NERVOUS SYSTEM.
scribed it. Luys and Lockhart Clarke first demonstrated that the cells of the
ventral horns of the spinal cord were diseased. Charcot separated two types —
one with simple wasting of the muscles, due, he believed, to degeneration
confined to the ventral horns (and to this he restricted the name progressive
muscular atrophy — type, Aran-Duchenne) ; the other, in which there was spas-
tic paralysis of the muscles followed by atrophy. As the anatomical basis for
this he assumed a primary degeneration of the pyramidal tracts and a second-
ary atrophy of the ventral horns. To this he gave the name of amyotrophic
lateral sclerosis. There is but little evidence, however, to show that any such
sharp distinction can be made between these two diseases, and Leyden and
Gowers regard them as identical.
Etiology. — The cause of the disease is unknown. It is more frequent in
males than in females. It affects adults, developing after the thirtieth year,
though occasionally younger persons are attacked. A large majority of all
cases of progressive muscular atrophy under twenty-five years of age belong
to the dystrophies. Cold, wet, exposure, fright, and mental worries are men-
tioned as possible causes. Erb has lately called attention to certain cases fol-
lowing injury. Hereditary influences are present in certain cases. The rare
form which occurs in infancy usually affects several members of the same
family. Hereditary and family influences, however, play but a small part in
the etiology of this disease, and in this it is in contrast to progressive neural
muscular atrophy and the dystrophies. Yet, in the Farr family, which I
recorded some years ago, in which thirteen members were affected in two gen-
erations, with the exception of two, the cases occurred or proved fatal above
the age of forty, and the late onset speaks rather for a central affection. The
spastic form may develop late in life — after seventy — as a senile change.
Morbid Anatomy. — The essential anatomical change is a slow degenera-
tion of the motor path, involving particularly the lower motor neurones.
The upper neurones are also involved, either first, simultaneously, or at a
later period. Associated with the degeneration in the cells of the ventral
horns there is a degenerative atrophy of the muscles.- The following are the
important anatomical changes: (a) The gray matter of the cord shows the
most marked alteration. The large ganglion cells of the ventral horns are
atrophied, or, in places, have entirely disappeared, the neuroglia is increased,
and the medullated fibres are much decreased. The fibres of the ventral
nerve-roots passing through the white matter are wasted, (h) The ventral
roots outside of the cord are also atrophied, (c) The muscles which are
affected show degenerative atrophy, and the inter-muscular branches of the
motor nerves are degenerated, (d) The degeneration of the gray matter is
rarely confined to the cord, but extends to the medulla, where the nuclei of
the motor cerebral nerves are found extensively wasted, (e) In a majority of
all the cases there is sclerosis in the ventro-lateral white tracts, the lateral
pyramidal tracts particularly are diseased, but the degeneration is not confined
to these tracts, and extends into the ventro-lateral ground bundles. The direct
cerebellar and the ventro-lateral ascending tracts are spared. The degenera-
tion in the pyramidal tracts extends toward the brain to different levels, and
in several cases has been traced to the motor cortex, the cells of which have
been found degenerated. In the medulla the medial longitudinal fasciculus
has been found diseased. (/) In those cases in which no sclerosis has been
SYSTEM DISEASES. 903
found in the pyramidal tracts there has been a sclerosis of the ventro-lateral
ground bundle (short tracts).
Symptoms. — Irregular pains may precede the onset of the wasting, and
cases may be treated for chronic rheumatism. The hands are usually first
affected, and there is difficulty in performing delicate manipulations. The
muscles of the ball of the thumb waste early, then the interossei and lum-
bricales, leaving marked depressions between the metacarpal bones. Ultimately
the contraction of the flexor and extensor muscles and the extreme atrophy
of the thumb muscles, the interossei, and lumbricales produces the claw-hand
— main en griff e of Duchenne. The flexors of the forearm are usually involved
before the extensors. In the shoulder-girdle the deltoid is first affected; it
may waste even before the other muscles of the upper extremity. The trunk
muscles are gradually attacked; the upper part of the trapezius long remains
unaffected. Owing to the feebleness of the muscles which support it, the head
tends to fall forward. The platysma myoides is unaffected and often hyper-
trophies. The arms and the trunk muscles may be much atrophied before the
legs are attacked. The face muscles are attacked late. Ultimately the inter-
costal and abdominal muscles may be involved, the wasting proceeds to an
extreme grade, and the patient may be actually " skin and bone," and, as,
" living skeletons," the cases are not uncommon in " museums " and " side-
shows." Deformities and contractures result, and lordosis is almost always
present. A curious twitching of the muscles (fibrillation) is a common symp-
tom, and may occur in muscles which are not yet attacked. It is a most
important symptom, but is not, as was formerly supposed, a characteristic
feature of the disease. The irritability of the muscles is increased. Sensa-
tion is unimpaired, but the patient may complain of numbness and coldness
of the affected limbs. The galvanic and faradic irritability of the muscles
progressively diminishes and may become extinct, the galvanic persisting for
the longer time. In cases of rapid wasting and paralysis the reaction of de-
generation may be obtained. The excitability of the nerve-trunks may persist
after the muscles have ceased to respond. The loss of power is usually pro-
portionate to the wasting.
The foregoing description applies to the group of cases in which the
atrophy and paralysis are flaccid — atonic, as Gowers calls it. In other cases,
those which Charcot describes as amyotrophic lateral sclerosis, spastic paraly-
sis precedes the wasting. This tonic atrophy first involves the arms and
then the legs. The reflexes are greatly increased. It is one of the rare con-
ditions in which a jaw clonus may be obtained. The most typical condition of
spastic paraplegia may be produced. On starting to walk, the patient seems
glued to the ground and makes ineffectual attempts to lift the toes ; then four
or five short, quick steps are taken on the toes with the body thrown forward ;
and finally he starts off, sometimes with great rapidity. Some of the patients
can walk up and down stairs better than on the level. The wasting is never
so extreme as in the atonic form, and the loss of power may be out of pro-
portion to it. The sphincters are unaffected. Sexual power may be lost early.
Cases are met with which correspond accurately to the clinical picture given
by Charcot of amyotrophic lateral sclerosis. These are not very common, and
it is much more usual to have a combination of the two types. A flaccid
atrophic paralysis with increased reflexes is often met with. These differences
904 DISEASES OF THE NERVOUS SYSTEM.
depend upon the relative extent of the involvement of the upper and lower
motor segments and the time of the involvement of each. The condition ma}^
be unilateral.
As the degeneration extends upward an important change takes place from
the development of bulbar symptoms, which may, however, precede the spinal
manifestations. The lips, tongue, face, pharynx, and larynx may be involved.
The lips may be affected and articulation impaired for years before serious
symptoms occur. In the final stage there may be tremor, the memory fails,
and a condition of dementia may develop.
Gowers gives the following useful classification of the varieties of this
affection: (1) Atonic atrophy, becoming extreme; (2) muscular weakness
with spasm, but without wasting or with only slight wasting; and (3) atonic
atrophj^, rarely extreme in degree, with exaggeration of the reflexes. These
conditions may " coexist in every degree and combination — between universal
atonic atrophy on the one hand and universal spastic paralysis without wast-
ing on the other."
Diagnosis. — Progressive (central) muscular atrophy begins, as a rule, in
adult life, without hereditary or family influences (the early infantile form
being an exception), and usually affects first the muscles of the thumb, and
gradually involves the interossei and lumbricales. Fibrillary contractions are
common, electrical changes occur, and the deep reflexes are usually increased.
These characteristics are usually sufficient to distinguish it from the other
forms of muscular wasting.
In syringo-myelia the symptoms may be very similar to those in the spastic
form of muscular atrophy. The sensory disturbances in the former disease,
as a rule, make the diagnosis clear, but when these are absent or but little
developed it may be very difficult or even impossible to distinguish the diseases.
Treatment. — The disease is incurable. I have never seen the slightest
benefit from drugs or electricity. The downward progress is slow but cer-
tain, though in a few cases a temporary arrest may take place. With a history
of syphilis, mercury and iodide of potassium may be tried, and Gowers recom-
mends courses of arsenic and the hypodermic injection of strychnine. Prob-
ably the most useful means is systematic massage, particularly in the spastic
cases.
Bulbar Paralysis (Glosso-Iahio-laryngeal Paralysis).
When the disease affects the motor nuclei of the medulla first or early, it
is called bulbar paralysis, but it has practically no independent existence, as
the spinal cord is sooner or later involved.
Symptoms. — The disease usually begins with slight defect in the speech,
and the patient has difficulty in pronouncing the dentals and Unguals. The
paralysis starts in the tongue, and the superior lingual muscle gradually be-
comes atrophied, and finally the mucous membrane is thrown into transverse
folds. In the process of wasting the fibrillary tremors are seen. Owing to
the loss of power in the tongue, the food is with difficulty pushed back into
the pharynx. The saliva also may be increased, and is apt to accumulate
in the mouth. When the lips become involved the patient can neither whistle
nor pronounce the labial consonants. The mouth looks large, the lips are
prominent, and there is constant drooling. The food is masticated with diffi-
SYSTEM DISEASES. 905
culty. Swallowing becomes difficult, owing partly to the regurgitation into
the nostrils, partly to the involvement of the pharyngeal muscles. The mus-
cles of the vocal cords waste and the voice becomes feeble, but the laryngeal
paralysis is rarely so extreme as that of the lips and tongue.
The course of the disease is slow but progressive. Death often results
from an aspiration pneumonia, sometimes from choking, more rarely from
involvement of the respiratory centres. The mind usually remains clear. The
patient may become emotional. In a majority of the cases the disease is only
part of a progressive atrophy, either simple or associated with a spastic con-
dition. In the later stage of amyotrophic lateral sclerosis the bulbar lesions
may paralyze the lips long before the pharynx or larynx becomes affected.,
The diagnosis of the disease is readily made, either in the acute or chronic
form. The involvement of the lips and tongue is usually well marked, while
that of the palate may be long deferred. A condition has been described,
however, which may closely simulate bulbar paralysis. This is the so-called
pseudo-hulhar form or bulbar palsy of cerebral origin. Bilateral disease of
the motor cortex in the lower part of the ascending frontal convolution, or
about the knee of the internal capsule, may cause paralysis of the lips and
tongue and pharynx, which closely simulates a lesion of the medulla. Some-
times the symptoms appear on one side, but in many instances they develop
suddenly on both sides. A bilateral lesion has usually been found, but in
several instances the disease was unilateral.
The so-called acute hulhar paralysis may be due to (a) hgemorrhagic or
embolic softening in the pons and medulla; (&) acute inflammatory softening,
analogous to polio-myelitis, occurring occasionally as a post-febrile affection.
It has occasionally followed diphtheria, and Mills and Weisenburg have re-
ported two fatal cases beginning with acute bulbar symptoms after severe
electric shocks of high voltage. It usually comes on very suddenly, hence the
term apoplectiform. The symptoms in this form may correspond closely to
those of an advanced case of chronic bulbar paralysis. The sudden onset and
the associated symptoms make the diagnosis easy. In these acute cases there
may be loss of power in one arm, or hemiplegia, sometimes alternate hemi-
plegia, with paralysis on one side of the face and loss of power on the other
side of the body.
2. Progressive Neural Muscular Atrophy.
This form, known also as the peroneal type, or by the names of the men
who have described it most accurately — namely, Charcot, Marie, and Tooth
— occurs either as a hereditary or as a family affection. It usually begins
in early childhood, affecting first the muscles of the feet and the peroneal
group; as a result of the weakening of these muscles, club-foot, either pes
equinus or pes equino-varus occurs. In rare instances the disease may be-
gin in the hands, but the upper limbs, as a rule, are not affected for some
years after the legs are attacked, and the trouble then begins in the small
muscles of the hands. Sensory disturbances are frequently present and form
important diagnostic features. Fibrillary contractions and twitchings also
occur. The electrical reactions are altered ; there is either a loss or a very
great decrease of the excitability, which can be demonstrated not only in
906 DISEASES OF THE NERVOUS SYSTEM.
the atrophic muscles, but also in muscles and nerves which are apparently
normal.
This form of muscular atrophy seems to stand between the central form
and the muscular dystrophies. Occurring in families and beginning in early
life, it resembles the latter, but it is more like the former in that fibrillary
contractions and muscular twitchings are common, that the small muscles of
the hand are apt to be involved, and that electrical changes are present. In
the prominence of sensory symptoms it differs from both. In cases of acquired
double club-foot this disease should be suspected.
3. The Muscular Dystrophies
[Dystrophia muscularis progressiva, Erb).
Definition. — Muscular wasting, with or without an initial hypertrophy,
beginning in various groups of muscles, usually progressive in character, and
dependent on primary changes in the muscles themselves. A marked hered-
itary disposition is met with in the disease.
Etiology. — 'No etiological factors of any moment are known other than
heredity. The influence may show itself by true heredity — the disease occur-
ring in two or more generations — or several members of the same generation
may be affected, showing a family tendency. Many members of the same
family may be attacked through several generations. Males, as a rule, are
more frequently affected than females. The disease is usually transmitted
through the mother, though she may not herself be affected. As many as 20
or 30 cases have been described in five generations. In Erb's cases 44 per cent
showed no heredity. The disease usually sets in before puberty, but may be
as late as the twentieth or twenty-fifth year, or in some instances even
later.
Symptoms. — The first sjnnptom noticed is, as a rule, clumsiness in the
movements of the child, and on examination certain muscles or groups of
muscles seem to be enlarged, particularly those of the calves. The extensors
of the leg, the glutei, the lumbar muscles, the deltoid, triceps and infra-
spinatus, are the next most frequently involved, and may stand out with
great prominence. The muscles of the neck, face, and forearm rarely suffer.
Sometimes only a portion of a muscle is involved. With this hypertrophy of
some muscles there is wasting of others, particularly the lower portion of
the pectorals and the latissimus dorsi. The attitude when standing is very
characteristic. The legs are far apart, the shoulders thrown back, the spine
is greatly curved, and the abdomen protrudes. The gait is waddling and
awkward. In getting up from the floor the position assumed, so well known
now through Gowers' figures, is pathognomonic. The patient first turns
over in the all-fours position and raises the trunk with his arms; the
hands are then moved along the ground until the knees are reached; then
with one hand upon a knee he lifts himself up, grasps the other knee, and
gradually pushes himself into the erect posture, as it has been expressed, by
climbing up his legs. The striking contrast between the feebleness of the
child and the powerful-looking pseudo-hypertrophic muscles is very character-
istic. The enlarged muscles may, however, be relatively very strong.
The course of the disease is slow, but progressive. Wasting proceeds and
SYSTEM DISEASES. 907
finally all traces of the enlarged condition of the muscles disappear. At this
late period distortions and contractions are common.
The muscles of the shoulder-girdle are nearly always affected early in the
disease, causing a symptom upon which Erb lays great stress. With the
hands under the arms, when one endeavors to lift the patient, the shoulders
are raised to the level of the ears, and one gets the impression as though the
child were slipping through. These " loose shoulders " are very character-
istic. The abnormal mobility of the shoulder-blades gives them a winged
appearance, and makes the arms seem much longer than usual when they are
stretched out.
The patients complain of no sensory symptoms. The atrophic mus-
cles do not show the reaction of degeneration except in extremely rare in-
stances.
Clinical Forms. — A number of different types have been described, depend-
ing upon the age at the onset, the muscles first affected, the occurrence of
hypertrophy, the prominence of heredity, etc. But Erb has shown that there
is no sharp division between these different forms, and classes them all under
the name of dystrophia muscularis progressiva. For convenience of descrip-
tion he subdivides the disease into two large groups :
I. Those cases which occur in childhood.
II. The cases occurring in youth and adult life.
The first division is subdivided into (1) the hypertrophic and (3) the
atrophic form.
Under the hypertrophic form, which is the pseudo-hypertrophic muscular
paralysis of authors, he thinks it is useful to distinguish between the cases in
which (a) the enlarged muscles have undergone lipomatosis — i. e., pseudo-
hypertrophy— from those (&) in which there is a real hypertrophy.
The atrophic form also includes two subclasses: (a) Those cases in which
the muscles of the face are involved early; this corresponds to the infantile
form of Duchenne — the Landouzy-Dejerine type. (&) Those cases in which
the face is not involved,
I. Dystrophia muscularis progressiva infantum.
1. Hypertrophic form.
(a) With pseudo-hypertrophy.
(&) With real hypertrophy.
2. Atrophic form.
(a) With primary involvement of the face (infantile form of
Duchenne).
(&) Without involvement of the face.
II. Dystrophia muscularis progressiva juvenum vel aduttorum (Erb's
juvenile form).
Morbid Anatomy. — According to Erb, the disease consists in a change in
the muscles themselves. At first the muscle-fibres hypertrophy, and become
round; the nuclei increase, and the muscle-fibres may become fissured. At
the same time there is a slight increase in the connective tissue. Sooner or
later the muscle-fibres begin to atrophy, and the nuclei become greatly in-
creased. Vacuoles and fissures appear, and the fibres finally become completely
atrophic, the connective tissue becoming markedly increased. Fat may be
deposited in the connective tissue to such an extent as to cause hypertrophic
908 DISEASES OF THE NERVOUS SYSTEM.
lipomatosis — pseuclo-h3^pertrophy. The different stages of these changes may
be found in a single muscle at the same time.
The nervous system has very generally been found to be without demon-
strable lesions, but in certain cases changes in the cells of the ventral horns
have been described.
Diagnosis. — The muscular dystrophies can usually be distinguished readily
from the other forms of muscular atrophy.
(a) In the cerebral atrophy loss of power usually precedes the atrophy,
which is either of a monoplegic or hemiplegic type.
(&) From progressive (central) muscular atrophy the distinctions are
plainly marked. This form begins in the small muscles of the hand, a situa-
tion rarely, if ever, affected by the dystrophies, which involve first those of
the calves, the trunk, the face, or the shoulder-girdle. In the central atrophy
the reaction of degeneration is present and fibrillary twitchings occur in both
the atrophied and non-atrophied muscles. In many cases, in addition to the
wasting in the arms, there is a spastic condition in the legs and increase in the
reflexes. The central atrophies come on late in life; the dystrophies develop,
as a rule, early. In the progressive muscular dystrophies heredity plays an
important role, which in the central form is quite subsidiary'. In the rare
cases of early infantile spinal muscular atrophy occurring in families the
symptoms are so characteristic of a central disease that the diagnosis presents
no difficulty.
(c) In the neuritic muscular atrophies, whether due to lead or to trauma,
the general characters and the mode of onset are distinctive. In the cases
of multiple neuritis seen for the first time • at a period when the wasting
is marked there is often difficulty, but the absence of family history and the
distribution are important features. Moreover, the paralysis is out of propor-
tion to the atrophy. Sensory symptoms may be present, and in the cases in
which the legs are chiefly involved there is usuall}^ the steppage gait so char-
acteristic of peripheral neuritis.
(d) Progressive neural muscular atrophy. Here heredity is also a factor,
and the disease usually begins in early life, but the distribution of atrophy
and paralysis, which in this affection is at first confined to the periphery of
the extremities, helps to distinguish it from the dystrophies ; while the occur-
rence of sensory sjanptoms, fibrillary contractions, and the marked decrease in
the electrical excitability usually make the distinction clear.
The outlook in the primary muscular dystrophies is bad. The wasting
progresses uniformly, uninfluenced by treatment. Erb holds that by electricity
and massage the progress is occasionally arrested. The general health should
be carefully looked after, moderate exercise allowed, frictions with oil applied
to the muscles, and when the patient becomes bedfast, as is inevitable sooner
or later, care should be taken to prevent contractures in awkward positions.
The three forms of progressive muscular wasting — progressive (central)
muscular atrophy, progressive neural muscular atrophy, and the muscular
dystrophies — have been considered as distinct diseases, but certain recent
writings make it probable that the distinction may not be so sharp as we
believe. Certain cases occur which seem not to belong to any one of the
forms but to stand between them. The changes in the muscles which were
thought to be characteristic of the dystrophies have been found in the other
SYSTEM DISEASES. 909
forms. The central form occurs as a family disease in infancy, and the nervous
system has been found diseased in the dystrophies.
The whole question is in a chaotic state, and it is at present better to
keep to the old divisions. Even if it should turn out to be true, as Striimpell
suggests, that all the forms depend upon a congenital tendency of the motor
system to degenerate, they represent well-defined clinical types, into which
the cases can, as a rule, be grouped without difficulty, while corresponding
to each there is a fairly well-determined anatomical basis.
B. SYSTEM DISEASES OF THE UPPEE MOTOR SEGMENT.
The question of an uncomplicated primary degeneration of the upper
motor neurones has not been decided. Cases with a clinical picture corre-
sponding to this lesion are not uncommon, and they may persist for a long
time without change. Unfortunately the cases which have come to autopsy
have shown various conditions. In only two or three has the disease been
so nearly confined to the pyramidal tract that they can be used as an argu-
ment for the independence of this condition. The cases of Minkowski, Dresch-
feld, and Striimpell are not absolutely conclusive, as they are not quite pure,
although they go far to prove that a degeneration in the pyramidal tract may
be uncomplicated, at least for a long time. The same may be said for the
group of cases described by Bernhardt and Striimpell under the name heredi-
tary spastic spinal paralysis, in which the extensive systemic degeneration of
the pyramidal tracts is combined with slight degeneration in other tracts of
the cord.
1. Spastic Paralysis of Adults
(Tabes dorsalis spasmodique; Primary Lateral Sclerosis).
Definition. — A gradual loss of power with spasm of the muscles of the
body, the lower extremities being first and most affected, unaccompanied by
muscular atrophy, sensory disturbance, or other symptoms. The pathological
anatomy is undetermined, but a systemic degeneration of the pyramidal tracts
is assumed.
Symptoms. — The general symptoms of spastic paraplegia in adults are very
distinctive. The patient complains of feeling tired, of stiffness in the legs, and
perhaps of pains of a dull aching character in the back or in the calves. There
may be no definite loss of power, even when the spastic condition is well
established. In other instances there is definite weakness. The stiffness is
felt most in the morning. In a well-developed case the gait is most char-
acteristic. The legs are moved stiffly and with hesitation, the toes drag and
catch against the ground, and, in extreme cases, when the ball of the foot
rests upon the ground a distinct clonus develops. The legs are kept close
together, the knees touch, and in certain cases the adductor spasm may cause
cross-legged progression. On examination, the legs may at first appear tol-
erably supple, perhaps flexed and extended readily. In other cases the rigidity
is marked, particularly when the limbs are extended. The spasm of the
adductors of the thigh may be so extreme that the legs are separated with
the greatest difficulty. In cases of this extreme rigidity the patient usually
loses the power of walking. The nutrition is well maintained, the muscles may
910 DISEASES OF THE NERVOUS SYSTEM.
be li^-pertropliied. The reflexes are greatly increased. The slightest touch
ujoon the patellar tendon produces an active knee-jerk. The rectus clonus
and the ankle clonus are easily obtained. In some instances the slightest
touch may throw the legs into ^dolent clonic spasm, the condition to which
Brown-Sequard gave the name of spinal epilepsy. The superficial reflexes
are also increased. The arms may be unaffected for years, but occasionally
thev become weak and stiff at the same time as the legs. This was the case
in a colored boy who was in my wards for several years. He presented a
degree of general spastic rigidity that I have never seen equalled. The disease
had begun after puberty, developed gradually, and remained quite stationary
for more than a year before he left the wards. There were no other sjTuptoms.
The course of the disease is progi'essively downward. Years may elapse
before the patient is bedridden. Involvement of the sphincters, as a rule,
is late; occasionally, however, it is early. The sensory sjonptoms rarely pro-
gress, and the patients may retain their general nutrition and enjoy excellent
health. Ocular s^inptoms are rare.
Diagnosis. — The diagnosis, so far as the clinical picture is concerned, is
readily made, but it is often very difficult to determine accurately the nature
of the underh-ing pathological condition. A history of syphilis is present in
many of the cases. Cases which have run a fairly typical clinical course upon
coming to autopsy have been found to have been due to very different condi-
tions— transverse myelitis, multiple sclerosis, cerebral tumor, etc. General
paralysis of the insane may begin with symptoms of spastic paraplegia, and
We5t|Dhal believed that it was only in relation to this disease that a primary
sclerosis of the 2^;^Tamidal tracts ever occurred. In any case the diagnosis
of primary systemic degeneration of the j^yramidal tract is, to say the least,
doubtful.
2. Spastic Paralysis of Ixfaxts — Spastic Diplegia — ^Bieth Palsies
(Paraplegia cerebralls spastica (Heine); Little's Disease).
In this condition there is a paralysis with spasm of all extremities, dating
from or shortly succeeding birth, more rarely following the fevers or an
attack of convulsions. The legs are usually more involved than the arms;
there is no wasting, no disturbance of sensation. The reflexes are increased.
The mental condition is usually much disturbed. The patients are often
imbeciles or idiots, helpless in mind and body. Ataxic and athetoid move-
ments of the most exaggerated kind may occur.
While only a limited number of cases of infantile hemiplegia are con-
genital, on the other hand, in spastic diplegia and paraplegia a large pro-
portion of the cases results from injury at birth. The arms may be so slightly
affected as to make it difficult to determine whether it is a case of diplegia or
paraplegia. The disease usually dates from birth, and a majority of the chil-
dren are born in first labors or are forceps cases, and are at birth asph}mated
blue babies. Pioss suggests that in feet presentations there may be laceration
or tearing of the cerebro- spinal membranes. Premature birth is also given as
a cause.
Morbid Anatomy. — The birth palsies which ultimately induce the spastic
diplegias or paraplegias are most frequently the result of meningeal hsemor-
SYSTEM DISEASES. 911
rhage. The importance of this condition has been shown by the studies of
Litzmann and Sarah J, McNutt. The bleeding may come from the veins,
or, as in one case which I saw with Hirst, from the longitudinal sinus. The
haemorrhage has in many cases been thickest over the motor areas, and in these
cases the intelligence may suffer but little ; with a more extensive haemorrhage,
especially when it implicates the frontal lobes, any grade of amentia may
be occasioned. It seems probable that the sclerosis found in these cases may
result from compression by the blood-clot. In other instances the condition
may be due to a foetal meningo-encephalitis. In 16 autopsies collected in
the literature, in which the patients died at ages varying from two to thirty,
the anatomical condition was either a diffuse atrophy, which was most com-
mon, or porencephalus. From the fact that certain of the cases are bdtn
prematurely, before the pyramidal tracts are developed, it has been assumed
by some that a non-development of these tracts is the cause of the disease.
This hypothesis has been urged by Marie, who limits the name spastic para-
plegia to that group of the infantile cases in which there is no evidence of
involvement of the brain — intellectual disturbances, epilepsy, etc., and it is
in these cases that he believes the pyramidal tract has remained undeveloped.
Symptoms. — At first nothing abnormal may be noticed about the child. In
some instances there have been early and frequent convulsions; then at
the age when the child should begin to walk it is noticed that the limbs are
not used readily, and on examination a stiffness of the legs and arms is found.
Even at the age of two the child may not be able to sit up, and often the
head is not well supported by the neck muscles. The rigidity, as a rule, is
more marked in the legs, and there is an adductor spasm. When supported on
the feet, the child either rests on its toes and the inner surface of the feet,
with the knees close together, or the legs may be crossed. The stiffness of the
upper limbs varies. It may be scarcely noticeable or the rigidity may be as
marked as in the legs. When the spastic condition affects the arms as well as
the legs, we speak of the condition as diplegia; when the legs alone are in-
volved, as paraplegia. There seems to be no sufficient reason for considering
them separately. Constant irregular movements of the arms are not uncom-
mon. The child has great difficulty in grasping an object. The spasm and
weakness may be more evident on one side than the other. The mental con-
dition is, as a rule, defective and convulsive seizures are common.
Associated with the spastic paralysis are two allied conditions of consid-
erable interest, characterized by spasm and disordered movements. A child
with spastic diplegia may present, in an unusual degree, irregular movements
of the muscles. In attempting to grasp an object the fingers may be thrown
out in a stiff, spasmodic, irregular manner, or there may be constant irregular
movements of the shoulders, arms, and hands, with slight incoordination of the
head. Cases of this description have been described as chorea spastica^ and
they may be difficult to separate from multiple sclerosis and from Friedreich's
ataxia.
A still more remarkable condition is that of hilateral athetosis, in which
there is a combination of spasm more or less marked with the most extraor-
dinary bizarre movements of the muscles. The condition, as a rule, dates from
infancy. The patient may not be able to walk. The head is turned from side
to side; there are continual irregular movements of the face muscles, and
912 DISEASES OF THE NERVOUS SYSTEM.
the mouth is drawn and greatly distorted. The extremities are more or less
rigid, particularly in extension. On the slightest attempt to move, often spon-
taneously, there are extraordinary movements of the arms and legs, particu-
larly of the arms, somewhat like athetosis, though much more exaggerated.
The patients are often unahle to help themselves on account of these move-
ments. The reflexes are increased. The mental condition is variable. The
patient may be idiotic, but in 3 of the 6 cases which I have seen the patients
were intelligent. Massalongo, who has carefully studied this condition, de-
scribes 3 cases in one family. I have collected 53 cases from the literature,
33 of which occurred in males and 20 in females.
Treatment. — Little can be done for these children when the symptoms are
extreme. In the milder cases patient training may do much to better the
mental state when feeble-mindedness accompanies the motor palsies. Exercises
and massage should be given for the spastic muscles, and in many instances
tenotomies and tendon transplantations may be helpful in improving the
usefulness particularly of the lower extremities. On the view that most of
these cases date back to an intracranial haemorrhage during parturition, it is
reasonable to suppose that an immediate operation with the removal of the
cortical clot — for the effusion of blood is usually on the surface of the hemi-
sphere— might ward off the disastrous consequences of compression on the
infant's brain. Four of these cases, with asphyxia and convulsions after
difficult labors, have been operated upon soon after birth by Gushing, and cor-
tical clots have been removed. In two cases there has seemingly been a com-
plete restoration to health and an avoidance of the usual spastic sequels.
3. Hereditary Spastic Paraplegia
(Hereditary Spastic Spinal Paralysis; Family form of Spastic Spinal
Paralysis) .
It is a family affection and only occasionally are the ascendants affected.
There are several forms :
1. The pure spastic paraplegia — Striimpell's type — in which two or more
members of a family are attacked. Trunk, arms, and brain are not affected.
2. Mixed forms: (a) with features of multiple sclerosis as described by
Cestan and Guillain; (&) amyotrophic lateral sclerosis type, with the added
feature of atrophy; (c) forms resembling Friedreich's ataxia and the hered-
itary cerebellar ataxia; (d) forms resembling cerebral diplegia.
In a majority of the cases the disease begins in children between the seventh
and the fifteenth years. It may not develop until the twentieth year. Two,
three, or four members of a family are affected. Beginning in the legs with
characteristic spastic gait and all the features of an ordinary spinal paralysis,
the disease may extend and affect the arms, or there are added the symptoms
of multiple sclerosis or of one of the other above-named affections. Boys are
more often affected than girls, 88 to 51, in the cases collected by Delearde and
Minet (1908).
The pathology of the disease is still under discussion.
Amaurotic Family Idiocy (Sachs' Disease). — A remarkable form of in-
fantile paralysis has been described by Sachs, Peterson, and Hirsch. The dis-
SYSTEM DISEASES. 913
ease is one which involves the entire gray matter of the central nervous system.
The symptoms as summarized by Sachs are: 1. Psychic disturbances that
appear in early life (first or second year) and progress to total idiocy. 2.
Paresis, and ultimately complete paralysis of the extremities, which may be
either flaccid or spastic. 3. Increased, decreased, or normal tendon reflexes.
4. Partial, followed by total blindness (macular changes, with subsequent
atrophy of the optic nerve) . 5. Marasmus and death, usually before the second
year. 6. Distinct familial type. Occasional symptoms are nystagmus, stra-
bismus, hyperacusis, or impairment of hearing. The pathological changes
are primitive type of the cerebral convolutions, macrogyria, degenerative
changes in the large pyramidal cells, absence of the tangential fibres, and
decrease of the fibres of the white matter. The blood-vessels are normal.
There is also degeneration of the pyramidal columns of the cord. Of 27 cases
collected by Sachs, 17 occurred in six families ; all in Jews.
4. Erb's Syphilitic Spinal Paralysis.
Erb has described a symptom group under the term syphilitic spinal
paralysis, to which much attention has been given. The points upon which
he lays stress are a very gradual onset with a development finally of the fea-
tures of a spastic paresis; the tendon reflexes are greatly increased, but the
muscular rigidity is slight in comparison with the exaggerated deep reflexes.
There is rarely much pain, and the sensory disturbances are trivial, but there
may be paresthesia and the girdle sensation. The bladder and rectum are
usually involved, and there is sexual failure or impotence. And, lastly, im-
provement is not infrequent. A majority of instances of spastic paralysis of
adults not the result of slow compression of the cord are associated with
syphilis and belong to this group.
Erb thought the lesion to be a special form of transverse myelitis, but per-
haps it should be classed with the system diseases, under the name toxic spastic
spinal paralysis.
5. Secondary Spastic Paralysis.
Following any lesion of the pyramidal tract we may have spastic paralysis ;
thus, in a transverse lesion of the cord, whether the result of slow compression
(as in caries), chronic myelitis, the pressure of tumor, chronic meningo-mye-
litis, or multiple sclerosis, degeneration takes place in the pyramidal tracts,
below the point of disease. The legs soon become stiff and rigid, and the
reflexes increase.' Bastian has shown that in compression paraplegia if the
transverse lesion is complete, the limbs may be flaccid, without increase in the
reflexes — paraplegic flasque of the French. The condition of the patient
in these secondary forms varies very much. In chronic myelitis or in mul-
tiple sclerosis he may be able to walk about, but with a characteristic spastic
gait. In the compression myelitis, in fracture, or in caries, there may be
complete loss of power with rigidity.
It may be difficult or even impossible to distinguish these cases from those
of primary spastic paralysis. Eeliance is to be placed upon the associated
symptoms; when these are absent no deflnite diagnosis as to the cause of the
spastic paralysis can be given.
59
914 DISEASES OF THE NERVOUS SYSTEM.
6. Hysterical Spastic Paeaplegia.
There is no spinal-cord disease which may be so accurately mimicked as
spastic paraplegia. In the hysterical form there is wasting, the sensory symp-
toms are not marked, the loss of power is not complete, and there is not that
extensor spasm so characteristic of organic disease. The reflexes are, as a
rule, increased. The knee-jerk is present, and there may be a well-developed
ankle clonus. Gowers calls attention to the fact that it is usually a spurious
clonus, "due to a half -voluntary contraction in the calf muscles." A true
clonus does occur, however, and there may be the greatest difficulty in deter-
mining whether or not the case is one of hysterical paraplegia. The hysterical
contracture will be considered later.
C. SYSTEM DISEASES OF THE LOWEE MOTOE SEGMENT.
1. Chronic Anterior Polio-myelitis
(Progressive Muscular Atrophy — Aran-Duclienne) .
This disease has been considered as one of the types making up the pro-
gressive (central) muscular atrophies. In certain rare cases the process is
confined to the lower motor segment. They, however, differ so little clinically
from many of the cases in which the pyramidal tracts are involved that it
seems better to make no sharp distinction between them. The same may be
said of chronic bulbar paralysis.
2. Ophthalmoplegia.
This disease is at times due to a chronic degeneration of the nuclei of the
motor nerves of the eyeballs, and so is a system disease of the lower motor seg-
ment. It is treated of in connection with the other ocular palsies for the sake
of simplicity and because all ophthalmoplegias are not due to nuclear disease.
3. Acute Anterior Polio-myelitis
(Epidemic and Sporadic).
Definition. — An acute infection of unknown origin occurring at times in
epidemic form, more usually as sporadic eases, characterized anatomically in
the former by wide-spread lesions in the spinal cord and brain, in the latter
by an acute myelitis of the anterior horns.
Etiology. — Small epidemics have been described from time to time, par-
ticularly in Norway and in the United States. In 1905-6 there were in the
former country many outbreaks — 1,053 cases in all, with 145 deaths. In
1907-8 a serious epidemic occurred in New York City. About 2,000 cases
occurred, with 6 to 7 per cent mortality. Harbitz and Schiel in their mono-
graph describe very fully the Norwegian outbreaks, which have been chiefly
in country districts, though there have been numerous cases in Christiania;
some years ago Medin reported two outbreaks in and about Stockholm. Until
the New York experience just mentioned the United States epidemics have
been in country districts. The autumn months have been the periods of the
SYSTEM DISEASES. 915
greatest number of cases. A special feature of this form is the large number
of adults. The sporadic form is a widely distributed disease of children from
the second to the fourth year. It rarely proves fatal. For 1905 no cases are
reported in the Eegistrar General's returns for England and Wales. Sink-
ler's" observations show that the incidence of the disease is greatest in the
summer. The cause is unknown. It has been attributed to cold, overexertion,
and to falls. From the days of Mephibosheth infantile paralysis has been
attributed to the carelessness of nurses in letting the children fall. In young
adults overexertion may have an influence. I saw one case which followed
unusual effort in a football match. In the recent epidemics the bacteriology
of the disease has been studied, but without definite results.
Morbid Anatomy. — In the epidemic form wide-spread changes are met
with. Harbitz and Schiel report on 19 cases. There was nothing in the
throat or nose. In the spinal cord the gray matter was chiefly affected, the
anterior horns more severely and in close relation with the blood-vessels.
The ganglion cells were greatly degenerated. There were changes in the pia
mater with lymphocytic infiltration. Above the cord this slight infiltration
of the pia could also be traced even to the hemispheres. In the medulla and
pons many of the nuclei were involved in a hgemorrhagic inflammation, and
infiltrations and degenerations were found in the gray matter of the hemi-
spheres. In the severe cases the anatomical picture is that of a diffuse
meningo-myelitis and encephalitis. In the milder cases, too, the changes found
were very wide-spread. The morbid anatomy of the sporadic form has been
carefully studied. In his Goulstonian lectures, 1904, Buzzard gives in full
detail the lesions which are those of an acute hsemorrhagic poliomyelitis. In
cases in which the examination is not made for some months or years the
changes are very characteristic. The ventral cornu in the affected region is
greatly atrophied and the large motor cells are either entirely absent or only
a few remain. The affected half of the cord may be considerably smaller than
the other. The ventro-lateral column may show slight sclerotic changes, chiefly
in the pyramidal tract. The corresponding ventral nerve roots are atrophied,
and the muscles are wasted and gradually undergo a fatty and sclerotic change.
Symptoms. — The epidemic form presents special features. I have already
mentioned that young adults are frequently attacked. There are remarkable
abortive forms — cases with transient fever, headaches, vomiting, twitchings of
the limbs, but without subsequent paralysis. Bulbar cases have occurred in
which the localization was in the medulla with a rapid course of from two
to eight days. And, lastly, there are a few cases with the symptoms of an
acute meningo-encephalitis, coma, convulsions, rigidity, without local paralysis.
These features were noted by many observers in the New York epidemic.
In a majority of the cases of the sporadic form, after slight indisposi-
tion and feverishness, the child is noticed to have lost the use of one limb.
Convulsions at the outset are rare, not constant as in the acute cerebral
palsies of children. Fever is usually present, the temperature rising to 101°,
sometimes to 103°. Pain is often complained of in the early stages. This may
be localized in the back or between the shoulders ; any pressure on the paralyzed
limbs may be painful, causing the patient to cry out when he is moved in bed.
The paralysis is abrupt in its onset and, as a rule, is not progressive, but reaches
its maximum in a very short time, even within twenty-four hours. It is rarely
916 DISEASES OF THE NERVOUS SYSTEM.
generalized. The suddenness of onset is remarkable and suggests a primary
affection of the blood-vessels, a view which the haemorrhagic character of the
early lesion supports. The distribution of the paralysis is very variable. Its
irregularity and lack of symmetry is quite characteristic of the disease. One
or both arms may be affected, one arm and one leg, or both legs; or it may
be a crossed paralysis, the right leg and the left arm. In the upper extremi-
ties the paralysis is rarely complete and groups of muscles may be affected.
As Eemak has pointed out, there is an upper-arm and a lower-arm type of
palsy. The deltoid, the biceps, brachialis anticus, the supinator longus may
be affected in the former, and in the latter the extensors or flexors of the fingers
and wrists. This distribution is due to the fact that muscles acting function-
ally together are represented near each other in the spinal cord.
In the legs the tibialis anticus and extensor groups of muscles are more
affected than the hamstrings and glutei. The muscles of the face are very
rarely, the sphincters hardly ever involved. While the rule is for the paralysis
to be abrupt and sudden, there are cases in which it comes on slowly and takes
from three to five days for its development. At first the affected limb looks
natural, and as children between two and three are usually fat, very little
change may be noticed for some time; but the atrophy proceeds rapidly, and
the limb becomes flaccid and feels soft and flabby. Usually as early as the
end of the first week the reaction of degeneration is present. The nerves are
found to have lost their irritability. The muscles do not react to the induced
current, but to the constant current they respond by a sluggish contraction,
usually to a weaker current than is normal. The paralysis remains stationary
for a time, and then there is gradual improvement. Complete recovery is rare,
and, when the anatomical condition is considered, is scarcely to be expected.
The large motor cells of the cornua, when thoroughly disintegrated, can not be
restored. In too many cases the improvement is only slight, and permanent
paralysis remains in certain groups. Sensation is unaffected ; the skin reflexes
are absent, and the deep reflexes in the affected muscles are usually lost.
When the paralysis persists the wasting is extreme, the growth of the bones
of the affected limb is arrested, or at any rate retarded, and the joints may be
very relaxed; as, for instance, when the deltoid is affected, the head of the
humerus is no longer kept in contact with the glenoid cavity. In the later
stages very serious deformities may be produced by the shortening of the
unopposed intact muscles.
Diagnosis. — The condition is only too evident in the majority of cases.
There is a flaccid, flabby paralysis of one or more limbs which has set in
abruptty. The rapid wasting, the lax state of the muscles, the electrical reac-
tions, and the absence of reflexes distinguish it from the cerebral palsies. In
multiple neuritis, a rare disease in childhood, the paralysis is bilaterally sym-
metrical, affects the muscles at the periphery of the limbs, and is combined
with sensory symptoms. The pseudo-paresis of rickets is a condition to be
carefully distinguished. In this the loss of power is in the legs, rapid atrophy
is not present, and certain movements are possible but painful. The general
hyperaesthesia of the skin, the characteristic changes in the bones, and the dif-
fuse sweats are present. Disease of the hip or knee may produce a pseudo-
paralysis which with care can be readily distinguished. Limp chorea may also
be confused with it.
SYSTEM DISEASES. 917
Prognosis. — The outlook in any case for complete recovery is bad. The
natural course of the disease must be borne in mind; the sudden onset, the
rapid but not progressive loss of power, a stationary period, then marked im-
provement in certain muscle groups, and finally in many cases contractures
and deformities. There is no other disease in which the physician is so often
subject to unjust criticism, and the friends should be told at the outset that
in the severe and extensive paralysis complete recovery should not be expected.
The best to be hoped for is a gradual restoration of power in certain muscle
groups. In estimating the probable grade of permanent paralysis, the electrical
examination is of great value.
Treatment. — The treatment of acute infantile paralysis has a bright and
a dark side. In a case of any extent complete recovery can not be expected;
on the other hand, it is remarkable how much improvement may finally take
place in a limb which is at first completely flaccid and helpless. The follow-
ing treatment may be pursued : If seen in the febrile stage, a brisk laxative
and a fever mixture may be given. The child should be in bed and the affected
limb or limbs vi^rapped in cotton. As in the great majority of cases the
damage is already done when the physician is called and the disease makes
no further progress, the application of blisters and other forms of counter-
irritation to the back is irrational and only cruel to the child.
The general nutrition should be carefully maintained by feeding the
child well, and taking it out of doors every day. . As soon as the child can
bear friction the affected part should be carefully rubbed ; at first once a day,
subsequently morning and evening. Any intelligent mother can be taught sys-
tematically to rub, knead, and pinch the muscles, using either the bare hand
or, better still, sweet oil or cod-liver oil. This is worth all the other measures
advised in the disease, and should be systematically practised for months, or
even, if necessary, a year or more. Electricity has a much more limited use,
and can not be compared with massage in maintaining the nutrition of the
muscles. The faradic current should be applied to those muscles which
respond. The essence of the treatment is in maintaining the nutrition of the
muscles, so that in the gradual improvement which takes place in parts, at
least, of the affected segments of the cord the motor impulses may have to
deal with well-nourished, not atrophied muscle fibres.
Of medicines, in the early stage ergot and belladonna have been warmly
recommended, but it is unlikely that they have the slightest influence. Later
in the disease strychnia may be used with advantage in one or two minim
doses of the liquor strychninse, which, if it has no other effect, is a useful tonic.
The most distressing cases are those which come under the notice of the
physician six, eight, or twelve months after the onset of the paralysis, when
one leg or one arm or both legs are flaccid and have little or no motion. Can
nothing be done ? A careful electrical test should be made to ascertain which
muscles respond. This may not be apparent at first, and several applications
may be necessary before any contractility is noticed. With a few lessons an
intelligent mother can be taught to use the electricity as well as to apply the
massage. If in a case in which the paralysis has lasted for six or eight months
no observable improvement takes place in the next six months with thorough
and systematic treatment, little or no hope can be entertained of further
change. '
918 DISEASES OF THE NERVOUS SYSTEM.
In the later stage care should be taken to prevent the deformities resulting
from the contractions. Great benefit often results from a carefully applied
apparatus. Surgical measures, particularl}^ the transplantation of tendons
from intact to paral3'zed groups of muscles in order to restore the motor bal-
ance of the extremity, have proven of distinct advantage in many cases. A
large number of these operations have been done in the past few years. Very
ingenious and complicated procedures are often carried out, and the partial
transference of function from a flexor to a paralyzed extensor, or from a pro-
nator to a paralyzed supinator muscle, or vice versa, may be satisfactorily
accomplished. It is possible that nerve anastomoses In favorable cases may
come to supplant these tendon transplantations.
4. Acute axd Subacute Polio-myelitis in Adults.
An acute polio-myelitis in adults, the exact counterpart of the disease in
children, is recognized. A majority, however, of the cases described under this
heading have been multiple neuritis; but the suddenness of onset, the rapid
wasting, and the marked reaction of degeneration are thought by some to be
distinguishing features. Multiple neuritis may, however, set in with rapidity ;
there may be great wasting and the reaction of degeneration is sometimes
present. The time element alone may determine the true nature. Recovery
in a case of extensive multiple paralysis from polio-myelitis will certainly be
with loss of power in certain groups of muscles ; whereas, in multiple neuritis
the recovery, while slow, may be perfect.
The subacute form, the paralysie generate spinale anterieure subaigue of
Diichenne, is in all probability a peripheral palsy. The paralysis usually begins
in the legs with atrophy of the muscles, then the arms are involved, but not
the face. Sensation, as a rule, is not involved.
5. Acute Ascexdixg (Laxdrt's) Paralysis.
Definition. — An ascending flaccid paralysis, beginning in the legs, rapidl}^
extending to the trunk and arms, and finally involving the muscles of respira-
tion. Sensation and electrical reactions are normal, and there is retention of
sphincter control.
Etiology and Pathology. — This disease occurs most commonly in males
between the twentieth and thirtieth years. It has sometimes followed the
specific fevers. Many of the common pathogenic organisms may, especially
in patients debilitated by disease, give rise to sjanptoms of acute ascending
paralysis and can produce changes in the cord and nerves resembling those
found in Landrj^^s paralysis. Thus the t3^hoid bacillus may produce clinically
an acute ascending paralysis. The most recent careful studies have not solved
the problem of this remarkable disease. There are two views : First, that it is
a peripheral neuritis (Ross, Xeuwerk, Earth, and many others). Spiller
in a rapidly fatal case found destructive changes in the peripheral nerves
and corresponding alterations in the cell bodies of the ventral horns. He sug-
gests that the toxic agent acts on the lower motor neurones as a whole, and
that possibly the reason why no lesions were found in some of the cases ia
that the more delicate histological methods were not used. Buzzard has iso-
lated in pure culture in one case a micrococcus (M. tliecalis), and found
SYSTEM DISEASES. 919
the organism in large numbers in the tissues outside the spinal dura. Sec-
ondly, that it is a functional disorder without a recognizable anatomical
basis. Eecent negative autopsies support this view. While waiting for addi-
tional light, we may regard the disease as an acute poisoning of the lower
motor neurones.
Symptoms. — Weakness of the legs, gradually progressing, often with toler-
able rapidity, is the first symptom. In some cases within a few hours the
paralysis of the legs becomes complete. The muscles of the trunk are next
affected, and within a few days, or even less in more acute cases, the arms
are also involved. The neck muscles are next attacked, and finally the muscles
of respiration, deglutition, and articulation. The reflexes are lost, but the
muscles neither waste nor show electrical changes. The sensory symptoms are
variable; in some cases tingling, numbness, and hypersethesia have been
present. In the more characteristic cases sensation is intact and the sphincters
are uninvolved. Enlargement of the spleen, which occurred in the only two
cases in my wards, has been noticed in several other cases. The course of the
disease is variable. It may prove fatal in less than two days. Other cases
persist for a week or for two weeks. In a large proportion of the cases the
disease is fatal. One patient was kept alive for 41 days by artificial respira-
tion (C. L. Greene).
Diagnosis. — The diagnosis is difficult, particularly from certain forms of
multiple neuritis, and if we include in Landry's paralysis the cases in which
sensation is involved, distinction between the two affections is impossible. We
apparently have to recognize the existence of a rapidly advancing motor par-
alysis without involvement of the sphincters, without wasting or electrical
changes in the muscles, without trophic lesions, and without fever — features
sufficient to distinguish it from either the acute central myelitis or the polio-
myelitis anterior. It is doubtful, however, whether these characters always
suffice to enable us to differentiate the cases of multiple neuritis.
IV. COMBINED SYSTEM DISEASES.
When the disease is not confined within the limits of either the afferent
or efferent systems, but affects both, it is known as a combined system disease.
Some authors contend that the diseases usually classed under this head are
not really system diseases, but are diffuse processes. This is the view taken
by Leyden and Goldscheider, who limit the term system disease to locomotor
ataxia and progressive muscular atrophy.
In certain cases of locomotor ataxia which have run a fairly typical course
there may be found after death, besides the anatomical picture corresponding
to this disease, a moderate degeneration of the pyramidal tracts and of the
ventral horns. In progressive muscular atrophy, on the other hand, there
may be degeneration in the dorsal columns. During life these secondary in-
volvements of other systems, as they may be termed, may or may not be
accompanied by demonstrable symptoms, and when such do occur they make
their appearance late in the disease.
There is another group of cases in which from the very first the symptoms
point to an involvement of both the afferent and efferent systems, and it is
to these that the term primary combined system disease is usually limited.
920 DISEASES OF THE NERVOUS SYSTEM.
1. Ataxic Paraplegia.
This name is applied by Gowers to a disease characterized clinically by a
combination of ataxia and spastic paraplegia, and anatomically by involvement
of the dorsal and lateral columns.
The disease is most common in middle-aged males. Exposure to cold and
traumatism have been occasional antecedents. In striking contrast to ordi-
nary tabes a history of syphilis is rarely to be obtained.
The anatomical features are a sclerosis of the dorsal columns, which is
not more marked in the lumbar region and not specially localized in the root
zone of the cuneate fasciculi. The involvement of the lateral columns is
diffuse, not always limited to the pyramidal tracts, and there may be an
annular sclerosis. Marie believes that in many cases the distribution of the
sclerosis is due to the arterial supply and not to a true systemic degeneration,
the vessels involved being branches of the dorsal spinal artery.
The symptoms are well defined. The patient complains of a tired feeling
in the legs, not often of actual pain. The sensory symptoms of true tabes are
absent. An unsteadiness in the gait gradually develops with progressive weak-
ness. The reflexes are increased from the outset, and there may be well-
developed ankle clonus. Eigiditv of the legs slowly comes on, but it is rarely
so marked as in the uncomplicated cases of lateral sclerosis. From the start
incoordination is a well-characterized feature, and the difficulty of walking
in the dark, or swaying when the eyes are closed may, as in true tabes, be
the first symptom to attract attention. In walking the patient uses a stick,
keeps the eyes fixed on the ground, the legs far apart, but the stamping gait,
with elevation and sudden descent of the feet, is not often seen. The inco-
ordination may extend to the arms. Sensory symptoms are rare, but Gowers
calls attention to a dull, aching pain in the sacral region. The sphincters usu-
■ally become involved. Eye sjmiptoms are rare. Late in the disease mental
s}Tnptoms may develop, similar to those of general paresis.
In well-marked cases the diagnosis is easy. The combination of marked
incoordination with retention of the reflexes and more or less spasm are char-
acteristic features. The absence of ocular and sensory symptoms is an impor-
tant point.
2. Primary Combin^ed Sclerosis (Putnam).
The studies of J. J. Putnam, Dana, Bastianelli, Eisien Eussell, Collier,
and Batten have separated from among the lesions of the cord a fairly well
defined disease, characterized anatomically by a diffuse degeneration, often in
discrete patches. The dorsal and lateral columns are constantly involved,
chiefly in the thoracic and cervical regions. The nerve roots and the gray
matter show no changes. The lesions have the " appearance of a non-systemic
primary neurone degeneration, not dependent upon antecedent inflammation "
(E.W.Taylor).
Of Putnam's 50 cases, 31 were women, all but 5 above thirty years old.
A majority of the patients were of small stature and slender frame, and in
many there had been a general lack of vigor and a chronic pallor and debility ;
7 presented profound anaemia. There was no luetic history. The relation of
this group to anaemia is interesting. Eussell, Batten, and Collier make three
SYSTEM DISEASES. 921
groups: (1) cavses of profound anaemia (and one may add of cachexia), in
which during life no symptoms were present, but in which tliere were found
combined scleroses of the cord post mortem; (2) cat.es of progressive pernicious
anaemia, in which spinal symptoms have occurred; (3) cases of chronic
sclerosis of the cord, in which there occurs, as a secondary feature, a severe
anaemia.
The symptoms are both sensory and motor. The onset is usually with
numbness in the extremities, progressive loss of strength, and emaciation.
Paraplegia gradually develops, before which there have been, as a rule, spastic
symptoms with exaggerated knee-jerk. The amis are affected less than the
legs. Mental symptoms suggestive of dementia paralytica may develop toward
the close.
3. Hereditary Ataxia (Friedreich's Ataxia).
In 1861 Friedreich reported 6 cases of a form of hereditary ataxia, and
the affection has usually gone by his name. Unfortunately, paramyoclonus
multiplex is also called Friedreich's disease; so it is best, if his name is used
in connection with this affection, to term it Friedreich's ataxia. It is a very
different disease in many respects from ordinary tabes. It may or may not
be hereditary. It is really a family disease, several brothers and sisters being,
as a rule, affected. The 143 cases analyzed by Griffith occurred in 71 unrelated
families. In his series inheritance of the disease itself occurred in only 33
cases. Various influences in the parents have been noted; alcoholism in only
7 cases. Syphilis has rarely been present. Of the 143 cases, 86 were males
and 57 females; The disease sets in early in life, and in Griffith's series 15
occurred before the age of two years, 39 before the sixth year, 45 between
the sixth and tenth, 20 between the eleventh and fifteenth, 18 between the
sixteenth and twentieth, and 5 between the twentieth and twenty-fifth years.
The morbid anatomy shows an extensive sclerosis of the dorsal and lateral
columns of the spinal cord. The periphery, and the cerebellar tracts are usu-
ally involved. The observations of Dejerine and Letulle are of special interest,
since they seem to indicate that the change in this disease is a neurogliar
(ectodermal) sclerosis, differing entirely from the ordinary spinal sclerosis.
According to this view, Friedreich's disease is a gliosis of the dorsal columns
due to developmental errors ; but the question is still unsettled.
Symptoms. — The ataxia differs somewhat from the ordinary form. The
incoordination begins in the legs, but the gait is peculiar. It is swaying,
irregular, and more like that of a drunken man. There is not the characteristic
stamping gait of the true tabes. Eomberg's symptom may or may not be
present. The ataxia of the arms occurs early and is very marked; the move-
ments are almost choreiform, irregular, and somewhat swajdng. In making
any voluntary movement the action is overdone, the prehension is claw-like,
and the fingers may be spread or overextended just before grasping an object.
The hand frequently moves about an object for a moment and then suddenly
pounces upon it. There are irregular, swaying movements of the head and
shoulders, some of which are choreiform. There is present in many cases what
is known as static ataxia, that is to say, ataxia of quiet action. It occurs when
the body is held erect or when a limb is extended — irregular, oscillating move-
ments of the head and body or of the extended limb.
60
922 DISEASES OF THE NERVOUS SYSTEM.
Sensory symptoms are not usually present. The deep reflexes are lost early
in the disease, and, next to the ataxia, this is the most constant and important
s}mip'tom (Striimpell) . The skin reflexes are usually normal, and the pupillary
reflex to light is practically never aflEected.
Xystagmus is a characteristic sj'mptom. Atrophy of the optic nerve rarely
occurs. A striking feature is early deformity of the feet. There is talipes
equinus, and the patient walks on the outer edge of the feet. The big toe is
flexed dorsally on the first phalanx. Scoliosis is very common.
Trophic lesions are rare. As the disease advances paralysis comes on and
may ultimately be complete. Some of the patients never walk.
Disturbance of speech is common. It is usually slow and scanning; the
expression is often dull ; the mental power is, as a rule, maintained, but late
in the disease becomes impaired.
Diagnosis. — The diagnosis of the disease is not difficult when several mem-
bers of a family are afE ected. The onset in childhood, the curious form of
incoordination, the loss of knee-kicks, the early talipes equinus, the posi-
tion of the great toe, the scoliosis, the nystagmus, and scanning speech make
up an unmistakable picture. The disease is often confounded with chorea,
with the ordinary form of which it has nothing in common. With hereditary
chorea it has certain similarities, but usually this disease does not set in until
after the thirtieth year.
The affection lasts for many years and is incurable. Care should be taken
to prevent contractures. ,''
CereieUar Type.
There is a form of hereditary ataxia, described by Marie "as cerelellar
Jieredo-ataxia, which starts later in life, after the age of twenty, with disa-
bility in the legs, but the gait is less ataxic than " groggy." The knee-jerks
are retained, and a spastic condition of the legs ultimately develops. There
is no scoliosis, nor does club-foot develop. Sanger Brown's cases, 25 in one
family, and J. H. Xefl's, 13, appear to belong to this type. The cerebellum
has been found atrophied in 2 cases.
4. Progressive Interstitial Hypertrophic Neuritis op Infants.
Under this imposing title Dejerine and Sottas described a rare and inter-
esting affection. It is a family disease, and begins in early life. The symp-
toms are those typical of locomotor ataxia, to which is added progressive mus-
cular atrophy, with involvement of the face and a hypertrophy and hardening
of the peripheral nerves. As the name indicates, it is an interstitial hyper-
trophic neuritis with secondary involvement of the dorsal columns of the cord.
This disease has been associated with progressive neural muscular atrophy, but
Dejerine has shown that it is quite distinct.
5. Toxic Combined Sclerosis.
Certain poisons cause changes in the lateral and dorsal columns of the
cord that resemble those of the combined system diseases. They have been
demonstrated in pellagra and in ergotism, and have already been described.
In pernicious anaemia and many chronic wasting diseases these scleroses occur,
and are believed to be due to the action of poisons produced within the system.
DIFFUSE DISEASES OF THE NERVOUS SYSTEM. 923
C. DIFFUSE DISEASES OF THE NERVOUS SYSTEM.
I. AFFECTIONS OF THE MENINGES.
Diseases of the Dura Mater (Pachymeningitis).
Pachymeningitis Externa. — Cerebral. — Haemorrhage often occurs as a
result of fracture. Inflammation of the external layer of the dura is rare.
Caries of the bone, either extension from middle-ear disease or due to syphilis,
is the principal cause. In the syphilitic cases there may be a great thickening
of the inner table and a large collection of pus between the dura and the bone.
Occasionally the pus is infiltrated between the two layers of the dura mater
or may extend through and cause a dura-arachnitis.
The symptoms of external pachymeningitis are indefinite. In the syph-
ilitic cases there may be a small sinus communicating with the exterior. Com-
pression symptoms may occur with or without paralysis.
Spinal. — An acute form may occur in syphilitic affections of the bones,
in tumors, and in aneurism. The symptoms are those of a compression of
the cord. A chronic form is much more common, and is a constant accom-
paniment of tuberculous caries of the spine. The internal surface of the dura
may be smooth, while the external is rough and covered with caseous masses.
The entire dura may be surrounded, or the process may be confined to the
ventral surface.
Pachymeningitis Interna. — This occurs in three forms: (1) Pseudo-mem-
branous, (2) purulent, and (3) hemorrhagic. The first two are unimportant.
Pseudo-membranous infiammation of the lining membrane of the dura is not
usually recognized, but a most characteristic example of it came under my
observation as a secondary process in pneumonia. Purulent pachymeningitis
may follow an injury, but is more commonly the result of extension from
infiammation of the pia. It is remarkable how rarely pus is found between
the dura and arachnoid membranes.
HuSiMORRHAGio PACHYMENINGITIS {HcEmatoma of the Dura Mater).
Cerebral Form. — This remarkable condition, first described by Virchow,
is very rare in general medical practice. During ten years no instance of it
came under my observation at the Montreal General Hospital, On the other
hand, in the post-mortem room of the Philadelphia Hospital, which received
material from a large almshouse and asylum, the cases were not uncommon,
and within three months I saw four characteristic examples, three of which
came from the medical wards. The frequency of the condition in asylum work
may he gathered from the fact that in 1,185 post mortems at the Government
Hospital for the Insane, Washington, to June 30, 1897, there were 197 cases
with "a true neo-membrane of internal pachymeningitis" (Blackburn). Of
these cases, 45 were chronic dementia, 37 were general paresis, 30 senile de-
mentia, 28 chronic mania, 28 chronic melancholia, 22 chronic epileptic insan-
ity, 6 acute mania, and 1 case imbecility. Forty-two of the cases were in
persons over seventy years of age.
■ It has also been found in profound anaemia and other diseases of the blood
924 DISEASES OF THE NERVOUS SYSTEM.
and of the blood-vessels, and is said to have followed certain of the acute
fevers. Herter has called attention to the not infrequent occurrence of the
lesion in badly nourished, cachectic children.
The morbid anatomy is interesting. Yirchow's view that the delicate vas-
cular membrane precedes the haemorrhage is undoubtedly correct. Practically
we see one of three conditions in these cases: {a) subdural vascular mem-
branes, often of extreme delicacy, formed by the penetration of blood-vessels
and granulation tissue into an inflammatory exudate (so-called '''organiza-
tion" of an inflammatory exudate); (h) simple subdural haemorrhage; (c)
a combination of the two, vascular membrane and blood-clot. Certainly the
vascular membrane may exist without a trace of hsemorrhage — simply a
fibrous sheet of varying thickness, permeated with large vessels, which may
form beautiful arborescent tufts. On the other hand, there are instances in
which the subdural haemorrhage is found alone, but it is possible that in
some of these at least the haemorrhage may have destroyed all trace of the
vascular membrane. In some cases a series of laminated clots are found,
forming a layer from 3 to 5 mm. in thickness. Cysts may occur within this
membrane. The source of the haemorrhage is probably the dural vessels.
Huguenin and others hold that the bleeding comes from the vessels of the
pia mater, but certainly in the early stage of the condition there is no evidence
of this; on the other hand, the highly vascular subdural membrane may be
seen covered with the thinnest possible sheeting of clot, which has evidently
come from the dura. The subdural haemorrhage is usually associated with
atrophy of the convolutions, and it is held that this is one reason why it is so
common in the insane, especially in dementia paralytica and dementia senilis.
We meet with the condition also in phthisis and various cachectic conditions
in which the cerebral wasting is as common and almost as marked as in cases
of insanity. Konig found in 135 cases of ha?morrhagic paclnmeningitis from
the Berlin Pathological Institute that, 2 3 per cent accompanied phthisis.
Atrophy, however, may not be the only factor.
The s}Tnptoms are indefinite, or there may be none at all, especially when
the hemorrhages are small or have occurred very gradually, and the diagnosis
can not be made with certainty. Headache has been a prominent symptom
in some cases, and when the condition exists on one side there may be hemi-
plegia. The most helpful sjonptoms for diagnosis, indicating that the haemor-
rhage in an apoplectic attack is meningeal, are (1) those referable to increased
intracranial pressure (slowing and irregularity of the pulse, vomiting, coma,
contracted pupils reacting to light slowly or not at all) and (2) paresis and
paralysis, graduall}' increasing in extent, accompanied by symptoms which
point to a cortical origin. Extensive bilateral disease may, however, exist
without any symptoms whatever.
Spinal Form. — The spinal pachymeningitis interna, described by Char-
cot and Joffroy, involves chiefly the cervical region (P. cervicalis liyper-
trophica). The space between the cord and the dura is occupied by a firm,
concentrically arranged, fibrinous growth, which is seen to have developed
within, not outside of, the dura mater. It is a condition anatomically
identical with the haemorrhagic pachymeningitis interna of the brain. The
cord is usually compressed ; the central canal may be dilated — ^hydromyelus —
and there are secondary degenerations. The nerve roots are involved in the
DIFFUSE DISEASES OF THE NERVOUS SYSTEM. 925
growth and are damaged and compressed. The extent is variable. It may be
limited to one segment, but more commonly involves a considerable portion of
the cervical enlargement. The disease is chronic, and in some cases presents
a characteristic group of symptoms. There are intense neuralgic pains in the
course of the nerves whose roots are involved. They are chiefly in the arms
and in the cervical region, and vary greatly in intensity. There may be hyper-
a?sthesia with numbness and tingling ; atrophic changes may develop, and there
may be areas of anaesthesia. Gradually motor disturbances appear ; the arms
become weak and the muscles atrophied, particularly in certain groups, as the
flexors of the hand. The extensors, on the other hand, remain intact, so that
the condition of claw-hand is gradually produced. The grade of the atrophy
depends much upon the extent of involvement of the cervical nerve roots, and
in many cases the atrophy of the muscles of the shoulders and arms becomes
extreme. The condition is one of cervical paraplegia, with contractures,
flexion of the wrist, and typical main en griff e. Usually before the arms are
greatly atrophied there are the symptoms of what the French writers term
the second stage — namely, involvement of the lower extremities and the grad-
ual production of a spastic paraplegia, which may develop several months after
the onset of the disease, and is due to secondary changes in the cord.
The disease runs a chronic course, lasting, perhaps, two or more years.
In a few instances, in which symptoms pointed definitely to this condition,
recovery has taken place. The disease is to be distinguished from amyotrophic
lateral sclerosis, syringomyelia, and tumors. From the first it" is separated by
the marked severity of the initial pains in the neck and arms ; from the second
by the absence of the sensory changes characteristic of syringomyelia. From
certain tumors it is very difficult to distinguish; in fact, the fibrinous layers
form a tumor around the cord.
The condition known as hcematoma of the dura mater may occur at any
part of the cord, or, in its slow, progressive form — pachymeningitis haem-
orrhagica interna — may be limited to the cervical region and produce the
symptoms just mentioned. It is sometimes extensive, and may coexist with
a similar condition of the cerebral dura. Cysts may occur filled with hsem-
orrhagic contents.
Diseases oe the Pia Mater (Acute Cerebrospinal Leptomeningitis).
Etiology. — Under cerebro-spinal fever and tuberculosis the two most im-
portant forms of meningitis have been described. Other conditions with which
meningitis is associated are: (1) The acute fevers, more particularly pneu-
monia, erysipelas, and septicaemia; less frequently small-pox, typhoid fever,
scarlet fever, measles, etc. (3) Injury or disease of the bones of the skull.
In this group by far the most frequent cause is necrosis of the petrous portion
of the temporal bone in chronic otitis. (3) Extension from disease of the
nose. Meningitis has followed perforation of the skull in sounding the frontal
sinuses, suppurative disease of these sinuses, and necroses of the cribriform
plate. As mentioned under cerebro-spinal fever, the infection is thought to
be possible through the nose. (4) As a terminal infection in chronic nephritis,
arterio-sclerosis, heart-disease, gout, and the wasting diseases of children.
The following etiological table of the acute forms of meningitis may be
useful to the student :
926
DISEASES OF THE NERVOUS SYSTEM.
ti> f 1. Of cerebro-spinal") (a) Sporadic. ) -r\- i • *. n i •
53 I fever. | (b) Epidemic. \ Diplococcus intracellularis
» - - • ^ Meninges involved alone or in a general (
pneumococus infection. \
I i 3
(1h I
Pneumococcic.
}
Pneumococcus.
tz
fc
w
^^
p-
(>-.
P4
p-:^
n3
pa
EH
C i
O
o
<5
02
. .
1. Tuberculous
r (a) Secondary lo pneumonia, en-
2. Pneumo- J doearditis, etc.
coccie. I (b) Secondary to disease or injury
(^ of cranium or its fossae.
{(a) Following local disease of cra-
nium or a local infection elsewhere.
(b) Terminal infection in various
chronic maladies.
4. Miscella- ( In typhoid fever, influenza, diph-
neous acute < theria, gonorrhoea, anthrax, actino-
infections. ( mycosis, and other acute diseases.
Bacillus tuberculosis,
Pneumococcus.
Various forms of staphy-
lococci and streptococci.
Typhoid bacillus, influ-
enza bacillus, diphtheria
bacillus, gonococcus, etc.
Morbid Anatomy. — The basal or cortical meninges may be chiefly attacked.
The degree of involvement of the spinal meninges varies. In the form asso-
ciated with pneumonia and ulcerative endocarditis the disease is bilateral and
usually limited to the cortex. In extension from disease of the ear it is often
unilateral and may be accompanied with abscess or with thrombosis of the
sinuses. In the non-tuberculous form in children, in the meningitis of chronic
Bright^s disease, and in cachectic conditions the base is usually involved. In
the cases secondary to pneumonia the effusion beneath the arachnoid may be
very thick and purulent, completely hiding the convolutions. The ventricles
also may be involved, though in these simple forms they rarely present the
distention and softening which is so frequent in the tuberculous meningitis.
For a more detailed description the student is referred to the sections on
cerebro-spinal fever and tuberculous meningitis.
Symptoms. — The clinical features of meningitis have already been de-
scribed at length in the diseases just referred to, and I shall here give a gen-
eral summary. I have already, on several occasions, called attention to the
fact that cortical meningitis is not to be recognized by any symptoms or set of
symptoms from a condition which may be produced by the poison of many
of the specific fevers. In the cases of so-called cerebral pneumonia, unless the
base is involved and the nerves afi'ected, the disease is unrecognizable, since
identical symptoms may be produced by intense engorgement of the meninges.
In typhoid fever, in which meningitis is very rare, the twitchings, spasms, and
retractions of the neck are almost invariably associated with cerebro-spinal
congestion, not with meningitis. Actual meningitis does, however, occur in
typhoid fever, and, as Ohlmacher's cases show, the typhoid bacilli may be
present in the exudate.
A knowledge of the etiology gives a very important clew. Thus, in middle-
ear disease the development of high fever, delirium, vomiting, convulsions, and
retraction of the head and neck would be extremely suggestive of meningitis
or abscess. Headache, which may be severe and continuous, is the most com-
mon symptom. While the patient remains conscious this is usually the chief
complaint, and even when semicomatose he may continue to groan and to
place his hand on his head. In the fevers, particularly in pneumonia, there
may be no complaint of headache. Delirium is frequently early, and is most
marked when the fever is high.' Convulsions are less common in simple than
in tuberculous meningitis. They were not present in a single instance in the
DIFFUSE DISEASES OF THE NERVOUS SYSTEM. 927
cases which I have seen in pneumonia, ulcerative endocarditis, or septicsemia.
In the simple meningitis of children they may occur. Epileptiform attacks
which come and go are highly characteristic of direct irritation of the cortex.
Eigidity and spasm or twitchings of the muscles are more common. Stiffness
and retraction of the muscles of the neck are important symptoms; but they
are by no means constant, and are most frequent when the inflammation is
extensive on the meninges of the cervical cord. There may be trismus, gritting
of the teeth, or spastic contraction of the abdominal muscles. Vomiting is
a common symptom in the early stages, particularly in basilar meningitis.
Constipation is usually present. In the late stages the urine and faces may be
passed involuntarily. Optic neuritis is rare in the meningitis of the cortex,
but is not uncommon when the base is involved. Leube lays stress on the
hyperaesthesia of the skin and muscles, especially of the muscles of the neck
and calves.
Important symptoms are due to lesions of the nerves at the base. Stra-
bismus or ptosis may occur. The facial nerve may be involved, producing
slight paralysis, or there may be damage to the fifth nerve, producing an-
aesthesia and, if the Grasserian ganglion is affected, trophic changes in the
cornea. The pupils are at first contracted, subsequently dilated, and perhaps
unequal. The reflexes in the extremities are often accentuated at the begin-
ning of the disease; later they are diminished or entirely abolished. Herpes
is common, particularly in the epidemic form.
Fever is present, moderate in grade, rarely rising above 103°. In the
non-tuberculous leptomeningitis of debilitated children and in Bright's dis-
ease there may be little or no fever. The pulse may be increased in frequency
at first, though this is unusual. One of the striking features of the disease
is the slowness of the pulse in relation to the temperature, even in the early
stages. Subsequently it may be irregular and still slower. The very rapid
emaciation which often occurs is doubtless to be referred to a disturbance of
the cerebral influence upon metabolism. Kernig's sign has been described
under cerebro-spinal fever. Lumbar puncture is exceedingly valuable for
diagnosis. Not only does this frequently prove indisputably the existence
of an acute meningitis, but the bacteriological examination may decide as
to the etiological factor, and thus yield a more rational basis for treat-
ment.
Treatment. — There are no remedies which in any way control the course
of acute meningitis. An ice-bag should be applied to the head and, if the
subject is young and full-blooded, general or local depletion may be practised.
Absolute rest and quiet should be enjoined. When disease of the ear is
present, a surgeon should be early called in consultation, and if there are
symptoms of meningo-encephalitis which can in any way be localized trephin-
ing should be practised. An occasional saline purge will do more to relieve
the congestion than blisters and local depletion. The warm baths, as recom-
mended by Aufrecht and described under cerebro-spinal fever, should be given
every three hours. It is possible that recovery may follow in the primary
pneumococcus form (Fetter). If counter-irritation is deemed essential, the
thermo-cautery may be lightly applied to the back of the neck. Large doses
of the perchloride of iron, iodide of potassium, and mercury are recommended
by some authors.
928 DISEASES OF THE NERVOUS SYSTEM.
The application of an ice-cap, attention to the bowels and stomach, and
keeping the fever within moderate limits by sponging, are the necessary meas-
ures in a disease recognized as almost invariably fatal, in which also the cases
of recovery are extremely doubtful. Quincke's lumbar puncture (see page
163) may be used as a therapeutic measure. Fiirbinger in one case removed
60 cc. of cloudy fluid, in which tubercle bacilli were found. The headache
and other cerebral symptoms disappeared, and the patient, a man of twenty,
recovered. Wallis Ord and Waterhouse report a case of recovery, in a child
of five years, after trephining and drainage. In a recent case Halsted made
an unsuccessful attempt to irrigate the cerebro-spinal meninges in the manner
suggested by Leonard Hill.
Posterior Basic Meningitis (Sporadic Cerebrospinal Fever).
Specially studied by Gee, Lees, and Barlow, this form is met with chiefly
in infants during the first year, 84 of 110 cases. It presents a marked sea-
sonal incidence the first half of the year. Anatomically there is found inflam-
mation with matting of the parts over the posterior part of the base of the
brain from the optic commissure to the medulla, and with distention of the
lateral, the third, and sometimes the fourth ventricle with turbid fluid. The
two most striking features clinically are retraction of the head and blindness.
The cervical opisthotonos is a most characteristic symptom. Extensor and
flexor spasms of the limbs also occur. There are remarkable crises, with chill,
increased fever, vomiting, and exaggeration of the spasms (Box). The prog-
nosis is bad, but recovery takes place in a few cases. Much discussion has
taken place as to the relation of this form to epidemic cerebro-spinal fever.
Still, Hunter, Nuttall, and others claim that the organism found corresponds
with the meningococcus, and with this view Koplik and other New York
observers agree. Houston and Eankin state that the organism of posterior
basic meningitis has much the same cultural characters, but differs entirely in
its opsonic and agglutinating powers; but Arkwright, in a careful study of
forty-five different strains, could not confirm this view.
Chronic Leptomeningitis. — This is rarely seen apart from syphilis or tuber-
culosis, in which the meningitis is associated with the growth of the granu-
lomata in the meninges and about the vessels. The symptoms in such cases
are extremely variable, depending entirely upon the situation of the growth.
The epidemic meningitis may run a very chronic course. The posterior basic
meningitis may be chronic. In the cases reported by Gee and Barlow the
duration in some instances extended even to a year and a half. Quincke's
meningitis serosa is considered with hydrocephalus.
II. SCLEROSES OF THE BRAIN.
General Remarks. — The supporting tissue of the central nervous system
is the neuroglia, derived from the ectoderm, with distinct morphological and
chemical characters. The meninges are composed of true connective tissue
derived from the mesoderm, a little of which enters the brain and cord with
the blood-vessels. The neuroglia plays the chief part in pathological processes
within the central nervous system, lout changes in the connective tissue ele-
DIFFUSE DISEASES OF THE NERVOUS SYSTEM. 929
ments may also be important. A convenient division of the cerebro-spinal
scleroses is into degenerative, inflammatory, and developmental forms.
The degenerative scleroses comprise the largest and most important sub-
division, in which provisionally the following groups may be made: (a) The
common secondary degeneration which follows when nerve-fibres are cut ofE
from their trophic centres (the severance of portions of neurones from the
main portions containing the nuclei) ; (h) toxic forms, among which may be
placed the scleroses from lead and ergot, and, most important of all, the
sclerosis of the dorsal columns, due in such a large proportion of cases to the
virus of syphilis. Other unknown toxic agents may possibly induce degenera-
tion of the nerve-fibres in certain tracts. The systemic paths in the cord
differ apparently in their susceptibility, and the dorsal columns appear most
prone to undergo this change; (c) the sclerosis associated with change in the
smaller arteries and capillaries, which is met with as a senile process in the
convolutions. In all probability some of the forms of insular sclerosis are
due to primary alterations in the blood-vessels; but it is not yet settled
whether the lesion in these cases is a primary degeneration of the nerve cells
and fibres to which the sclerosis is secondary, or whether the essential factor
is an alteration in nutrition caused by lesions of the capillaries and .smaller
arteries.
The inflammatory scleroses embrace a less important and less extensive
group, comprising secondary forms which develop in consequence of irritative
inflammation about tumors, foreign bodies, haemorrhages, and abscess. Histo-
logically these are chiefly mesodermic (vascular) scleroses, which arise from
the connective tissue about the blood-vessels. Possibly a similar change may
follow the primary, acute encephalitis, which Striimpell holds is the initial
lesion in the cortical sclerosis which is so commonly found post mortem in
infantile hemiplegia.
The developmental scleroses are believed to be of a purely neurogliar char-
acter, and embrace the new growth about the central canal in syringomyelia
and, according to recent French writers, the sclerosis of the dorsal columns
in Friedreich's ataxia. It is stated that histologically this form is different
from the ordinary variety. It may be, too, that the diffuse cortical sclerosis
met with as a congenital condition without thickening of the meninges belongs
to this type. It is not improbable that many forms of sclerosis are of a mixed
character, in which both the ectodertnic glia and mesodermic connective tissue
are involved.
Anatomically we meet with the following varieties:
(1) Miliary sclerosis is a term which has been applied to several, different
conditions. Gowers mentions a case in which there were grayish-red spots at
the junction of the white and gray matters, and in which the neuroglia was
increased. There is also a condition in which, on the surface of the convolu-
tions, there are small nodular projections, varying from a half to five or more
millimetres in diameter. Single nodules of this sort are not uncommon;
sometimes they are abundant. So far as is known no symptoms are produced
l)y them.
(2) Diffuse sclerosis, which may involve an entire hemisphere, or a single
lobe, in which case the term sclerose lohaire has been applied to it by the
French, It is not an important condition in general medical practice, but
930 DISEASES OF THE NERVOUS SYSTEM.
occurs most frequently in idiots and imbeciles. In extensive cortical sclerosis
of one hemisphere the ventricle is usually dilated.* The symptoms of this
condition depend upon the region affected. There may be a considerable
extent of sclerosis without symptoms or without much mental impairment.
In a majority of cases there is hemiplegia or diplegia with imbecilit}^ or
idiocy.
(3) Tuherous Sclerosis. — In this remarkable form, which is also known as
hypertrophic sclerosis, there are on the convolutions areas, projecting beyond
the surface, of an opaque white color and exceedingly firm. The sclerosis
may not disturb the s}Tametr\' of the convolution, but simply cause a great
enlargement, increase in the density, and a change in the color.
These three forms are not of much practical interest except in asylum and
institution work. The fourth variety forms a well-characterized disease of con-
siderable importance, namely, multiple sclerosis.
(i) Multiple (Insular: Disseminated) Sclerosis (Sclerose en plaques). —
DznxiTiox. — A chronic affection of the brain and cord, characterized by
localized areas in which the nerve elements are more or less replaced by
neuroglia. This may occur in. the brain or cord alone, more commonly in both.
The etiology is obscure. Kahler. ]\Iarie, and others assign great importance
to the infectious diseases, particularly scarlet fever. It is found most com-
monly in young persons, and cases are not uncommon in children.
]\IoKBiD AxATo:siT. — The sclerotic areas are widely distributed through
the brain and cord, and cases limited to either part alone are almost un-
known. The grayish-red areas are scattered indifferently through the white
and gray matter (E. W. Taylor). The patches are most abundant in the
neighborhood of the ventricles, and in the pons, cerebellum, basal ganglia,
and the medulla. The cord may be only slightly involved or there may be
very many areas throughout its length. The cervical region is apt to be
most affected. The nerve roots and the branches of the cauda equina are
often attacked. Histologically in the sclerosed patches ihere is a degeneration
of the medullary sheaths, with the persistence for some time of the axis-
cylinders. These naked axis-cylinders are thought by some to be new-formed
nerve-fibres. Accompanying this there is marked proliferation of the neu-
roglia, the fibres of which are denser and firmer. Secondary degeneration,
although relatively slight, does occur.
Symptoms. — The onset is slow and the disease is chronic. Feebleness of
the legs with irregular pains and stiffness are among the earl}^ S}Tnptoms.
Indeed, the clinical picture may be that of spastic paraplegia with great
increase in the refiexes. The following are the most important features :
(a) Volitional Tremor or So-called Intention Tremor. There is no paraly-
sis of the arms, but on attempting to pick up an object there is trembling
or rapid oscillation. A patient may be unable to lift even a glass of water
to the mouth. The tremor may be marked in the legs, and in the head,
which shakes as he walks. "When the patient is recumbent the muscles
may be perfectly quiet. On attempting to raise the head from the pillow,
trembling at once comes on. (&) Scanning Speech. — The words are pro-
*In my monograph on Cerebral Palsies of Children I have given a description of the
distribution of the sclerosis in ten specimens in the museum at the Elwvn Institution.
DIFFUSE AND FOCAL DISEASES OF THE SPINAL CORD. 931
nounced slowly and separately, or the individual syllables may be accentu-
ated. This staccato or syllabic utterance is a common feature, (c) Nys-
tagmus, a rapid oscillatory movement of both eyes, constitutes an important
symptom.
Sensation is unaffected in a majority of the cases. Optic atrophy often
occurs, but not so frequently as in tabes. The sphincters, as a rule, are
unaffected until the last stages. Mental debility is not uncommon. Remark-
able remissions occur in the course of the disease, in which for a time all
the symptoms may improve. Vertigo is common, and there may be sudden
attacks of coma, such as occur in general paresis.
The symptoms, on the whole, are extraordinarily variable, corresponding
to the very irregular distribution of the nodules.
Diagnosis. — The diagnosis in well-marked cases is easy. Volitional tremor,
scanning speech, and nystagmus form a characteristic symptom-group. With
this there is usually more or less spastic weakness of the legs. Paralysis agitans,
certain cases of general paresis, and occasionall)^ hysteria may simulate the
disease very closely. If the case is not seen until near the end the diagnosis
may be impossible. Buzzard holds that of all organic diseases of the nervous
system disseminated sclerosis in its early stages is that which is most com-
monly taken for hysteria. The points to be relied upon in the differentiation
are, in order of importance, optic atrophy, the nystagmus, the bladder disturb-
ances, when present, and the volitional tremor. The tremor in hysteria is not
volitional. Unilateral cases are recorded.
Much more puzzling, however, are the instances of pseudo-scUrose en
plaques, which have been described by Westphal. French writers regard them
as instances of hysterical tremor. In children the condition may with diffi-
culty be separated from Friedreich's ataxia.
The prognosis is unfavorable. Ultimately, the patient, if not carried off
by some intercurrent affection, becomes bedridden.
Treatment. — No known treatment has any influence on the progress of
sclerosis of the brain. Neither the iodides nor mercury have the slightest
effect, but a prolonged course of nitrate of silver may be tried, or arsenic.
The X-rays have been used with success (Eaymond).
D. DIFFUSE AND FOCAL DISEASES OE THE SPINAL
CORD.
I. TOPICAL DIAGNOSIS.
From the clinical symptoms presented by a spinal cord lesion it is pos-
sible for us to determine more or less accurately not only its segmental level but
also the transverse extent of the segmental involvement. The effects of an
injury or of disease processes may be circumscribed and involve the gray matter
of the segment or the tracts running through it only in part ; it may be more
extensive and involve the cord in a given level in its entire transverse ex-
tent; finally, there are cases in which only one lateral half of the cord is
implicated. It is well for the student to have a definite routine to follow in
making his examinations, for each factor may be helpful in determining the
932 DISEASES OF THE NERVOUS SYSTEM.
site and character of the lesion. Some of the more important points to
observe are the following: (1) subjective sensations, particularly the char-
acter and seat of pain, if any be present, such as the radiating pains of
dorsal root compression; (2) the patient's attitude, as the position of the
arms in cervical lesions, the character of the respiration, whether diaphrag-
matic, etc.; (3) motor symptoms, the groups of paralyzed muscles and their
electrical reaction; (4) the sensory symptoms, including tests for tactual, ther-
mic, and dolorous impressions, for muscle sense, bone sensation, etc.; (5) the
condition of the reflexes, both the tendon and the skin reflexes as well as
those for the pupil, the bladder and rectum, etc.; (6) the surface temperature
and condition of moisture or dryness of the skin, which gives an indication
of vaso-motor paralysis. The table on pages 871-873 and the figures on pages
878 and 879 will be useful while making an examination.
Focal Lesions. — We have seen that a lesion involving a definite part of the
gray matter of the spinal cord, owing to destruction of the cell bodies of the
lower motor neurones and consequent degeneration of their axis-cylinder proc-
esses, is accompanied by a loss of power to perform certain definite movements.
Thus a disease, such as anterior poliomyelitis, which is confined to the gray
matter, gives as its only symptom a characteristic flaccid paralysis, and the seat
of the lesion is revealed by the muscles involved. If from injury or disease
a lesion involves more than the gray matter and, for example, if the neigh-
boring fibres of the pyramidal tract be affected there may be in addition a
spastic paralysis of the muscles whose centres lie in the lower levels of the
cord. The degree of such a paralysis depends upon the intensity of the
lesion of the pyramidal tract and may vary from a slight weakness in dorsal/
flexion of the ankle to an absolute paralysis of all the muscles below the
lesion. Again, if the afferent tracts of the cord are affected sensory symptoms
may be added to the motor palsy. There may be disturbances of pain and\^
temperature sense alone or touch also may be affected. This, however, is
more rare except in serious lesions. The upper border of disturbed sensation
often indicates most clearly the level of the disease, especially when this is
in the thoracic region where the corresponding level of motor paralysis is
not easily demonstrated. It is unusual for cutaneous anaesthesia in organic
lesions of the cord to extend above the level of the second rib and the tip
of the shoulder, for this represents the lower border of the skin-field of
the fourth cervical (see sensory charts), and as the chief center for the dia-
phragm lies in this segment, a lesion at this level sufficiently serious to
cause sensory disturbances, would probably occasion motor paralyses as well
and would entirely shut off the movements necessary for respiration. It is
to be noted that the demonstrable upper border of the anaesthetic field may
not quite reach that which represents the level of the lesion. This is due to
the functional overlapping of the segmental skin- fields (Sherrington) and
applies more to touch than to pain and temperature. There is often a narrow
zone of hypersesthesia above the anaesthetic region.
Complete Transverse Lesions. — When the transverse lesion is total and
the lower part of the cord is cut off entirely from all influences from above,
there is complete sensory and motor paralysis up to the segmental level of
the injury, and the tendon reflexes, whose centres lie below, are lost instead
of being exaggerated, as they are apt to be in case the lesion is a focal one.
DIFFUSE AND FOCAL DISEASES OF THE SPINAL CORD. 933
The symptomatology of total transverse lesions in man has thus been given
by Collier. (1) Total flaccid paralysis of muscles below the level of the lesion.
(Spastic paralysis indicates that the lesion is incomplete.) (3) Permanent
abolition of the knee-jerk and other deep reflexes supplied by the lower seg-
ments of the cord. (3) A rapid wasting of the paralyzed muscles with a loss
of the faradic excitability. (4) The sphincters lose their tone and there is
dribbling. (5) There is total ansBsthesia to the level of the lesion (the zone
of hypersesthesia is rare). (6) The only sign of self-action remaining is in
the occasional presence, though in reduced degree, of certain skin reflexes
such as the plantar reflex with its dorsal flexor response in the great toe.
Unilateral Lesions. — The motor symptoms, which follow lesions limited
to one lateral half of the cross-section of the spinal cord, are confined to
one side of the body; they are on the same side as the lesion. At the level
of the lesion, owing to destruction of cell bodies of the lower system of
neurones, there will be found flaccid paralysis and atrophy of those muscles
whose centres of innervation happen to lie at this level. Owing to degeneration
of the pyramidal tract, the muscles whose centres lie at lower levels are also
paralyzed, but they retain their normal electrical reactions, become spastic,
and do not atrophy to any great degree.
Owing to the early crossing of the afferent paths in the cord, the sensory
symptoms are peculiar. On the side of the lesion — the paralyzed side — corre-
sponding to the segment or segments of the cord involved, there is a zone
of anaesthesia to all forms of sensation, but below this the sensitivity remains
normal or may be increased, for there is often hypersesthesia. The. muscle
sense, however, is impaired. On the side opposite to the lesion and nearly
up to its level there is complete loss of perception for pain and temperature
and there is more or less dulling of tactual sense as well.
The following table, slightly modified from Gowers, illustrates the dis-
tribution of these symptoms in a complete hemi-lesion of the cord:
Cord.
Zone of cutaneous hyperassthesia.
Zone of cutaneous anaesthesia.
Lower segment type of paralysis
with atrophy.
Lesion.
>.
Upper segment type of paralysis.
Hypersesthesia of skin.
Muscular sense impaired.
Reflex action first lessened and
then increased.
Surface temperature raised.
Muscular power normal.
Loss of sensibility of skin to pain
and temperature.
Muscular sense normal.
Reflex action normal.
Temperature same as that above
lesion.
This combination of symptoms was first recognized by Brown- Sequard,
after whom it has been named. It is common in syphilitic diseases of the
cord, may follow tumors, stab-wounds, and is not infrequently associated with
syringomyelia and haemorrhages into the cord. It is only in exceptional cases,
of course, that the lesion is absolutely limited to the hemi-section of the
cord and the symptoms consequently may vary somewhat in degree.
934 DISEASES OF THE NERVOUS SYSTEM.
The explanation of the disturbance in sensation is not entirely satisf actor}',
and can not be until our knowledge of the paths of sensory conduction is
more accurate. These cases have convinced most clinicians that in man the
paths for touch, pain, and temperature cross the middle line soon after
entering the spinal cord, and proceed toward the brain in the opposite
side, while that for muscular sense remains in the dorsal columns of the
same side. Anatomy lends some support to this view, and it is the explanation
usually given. The experiments on animals have thrown some doubt on this
view, especially those of Mott on monkeys, which seem to indicate that the
sensory paths for the most part remain on the same side of the cord.
U. AFFECTIONS OF THE BLOOD-VESSELS.
1. COXGESTIOX.
Apart from actual myelitis, we rarely see post-mortem evidences of con-
gestion of the spinal cord, and when we do, it is usually limited either to the
gray matter or to a definite portion of the organ. There is necessarily,
from the posture of the body post mortem, a greater degree of vascularity
in the dorsal portion of the cord. The white matter is rarely found con-
gested, even when inflamed; in fact, it is remarkable how uniformly pale
this portion of the cord is. The gray matter often has a reddish-pink tint,
but rarely a deep reddish hue, except when myelitis is present. If we know
little anatomically of conditions of congestion of the cord, we know less
clinically, for there are no features in any way characteristic of it.
2. Ax^iiiA.
So, too, with this state. There may be extreme grades of anemia of
the cord without symptoms. In chlorosis, for example, there are rarely
symptoms pointing to the cord, and there is no reason to suppose that such
sensations as heaviness in the limbs and tingling are especially associated
with ansmia.
There are, however, some very interesting facts with reference to the
profound anaemia of the cord which follows ligature of the aorta. In ex-
periments made in Welch's laboratory by Herter, it was found that within
a few moments after the application of the ligature to the aorta paraplegia
came on. Paralysis of the sphincters developed, but less rapidly. Eecent
observations made b}' Halsted on occlusion of the abdominal aorta in dogs
have shown that paraplegia occurs in a large percentage of cases, many of
which, however, may recover as the collateral circulation is established. In'
the fatal cases Gilman found extensive alterations in the cell bodies of
the lower part of the cord with degenerations. This condition is of interest
in connection with the occasional- rapid development of a paraplegia after
profuse hemorrhage, usually from the stomach or uterus. It may come
on at once or at the end of a week or ten days, and is probably due to
an anatomical change in the nerve elements similar to that produced in
Herter's experiments. The degeneration of the dorsal columns of the cord
in pernicious auEemia has already been described. ■ -
DIFFUSE AND FOCAL DISEASES OF THE SPINAL CORD. 935
3, Embolism and Thrombosis.
Blocking of the spinal arteries by emboli rarely occurs. It may, be pro-
duced experimentally, and Money found that it was associated with chorei-
form movements. Thrombosis of the smaller vessels in connection with endar-
teritis plays an important part in many of the acute and chronic changes
in the cord.
4. Endarteritis.
It is remarkable how frequently in persons over fifty the arteries of the
spinal cord are found sclerotic. The following forms may be met with:
(1) A nodular peri-arteritis or endarteritis associated with syphilis and
sometimes with gummata of the meninges;. (3) an arteritis obliterans, with
great thickening of the intima and narrowing of the lumen of the vessels,
involving chiefly the medium and larger-sized arteries. Miliary aneurisms
or aneurisms of the larger vessels are rarely found in the spinal cord. In
the classical work of Leyden but a single instance of the latter is mentioned.
5. HEMORRHAGE INTO THE SpINAL MeMBRANES ; H^MATORRHACHIS.
In meningeal apoplexy, as it is called, the blood may lie between the
dura mater and the spinal canal — extra-meningeal haemorrhage — or within
the dura mater — intra-meningeal hsemorrhage.
(a) Extra-meningeal haemorrhage occurs usually as a result of traumatism;
The exudation may be extensive without compression of the cord. The
blood comes from the large plexuses of veins which may surround the dura.
The rupture of an aneurism into the spinal canal may produce extensive
and rapidly fatal haemorrhage.
(6)^ Intra-meningeal haemorrhage is a less frequent result of trauma, but
in general is perhaps rather more common. It is rarely extensive from causes
acting directly on the spinal meninges themselves. Scattered hemorrhages
are not infrequent in the acute infectious fevers, and I have twice, in
malignant small-pox, seen much extravasation. Bleeding may occur also
in death from convulsive disorders, such as epilepsy, tetanus, and strychnia
poisoning, and has been recorded in association with difficult parturition.
The most extensive haemorrhages occur in cases in which the blood comes
from rupture of an aneurism at the base of the brain, either of the basilar
or vertebral artery. In several cases of this kind I have found a large
amount of blood in the spinal meninges. In ventricular apoplexy the blood
may pass from the fourth ventricle into the spinal meninges. There is
a specimen in the medical museum of McGill College of the most extensive
intraventricular haemorrhage, in which the blood passed into the fourth
ventricle, and descended beneath the spinal arachnoid for a considerable
distance. In cranial fractures, particularly those of the base of the skull,
the resultant haemorrhage almost always finds its way into the subarachnoid
space about the cord and may be demonstrated by the withdrawal of bloody
fluid by a lumbar puncture. The procedure is of considerable diagnostic value.
On the other hand, haemorrhage into the spinal meninges may possibly ascend
into the brain.
936 DISEASES OF THE NERVOUS SYSTEM,
Symptoms. — The symptoms in moderate grades may be slight and in-
definite. In the non-traumatic cases the haemorrhage may cither come on
suddenly or after a day or two of uneasy sensations along the spine. As
a rule, the onset is abrupt, with sharp pain in the back and symptoms of
iri;itation in the course of the nerves. There may be muscular spasms, or
paralysis may come on suddenly, either in the legs alone or both in the
legs and arms. In some instances the paralysis develops more slowly and
is not complete. There is no loss of consciousness, and there are no signs
of cerebral disturbance. The clinical picture naturally varies with the site
of the haemorrhage. If in the lumbar region, the legs alone are involved,
the reflexes may be abolished, and the action of the bladder and rectum is
impaired. If in the thoracic region, there is more or less complete paraplegia,
the reflexes are usually retained, and there are signs of disturbance in the
thoracic nerves, such as girdle sensations, pains, and sometimes eruption
of herpes. In the cervical region the arms as well as the legs may be involved ;
there may be difficulty in breathing, stiffness of the muscles of the neck,
and occasionally pupillar}^ symptoms.
The prognosis depends much upon the cause of the hgemorrhage. Ee-
covery may take place in the traumatic cases, and in those associated with
the infectious diseases.
6. HEMORRHAGE INTO THE SpINAL CoRD; HeMATOMYELIA.
Being most frequently a result of traumatism, an intraspinal hsemorrhage
is more common in males, and during the active period of life. Cases have
been known to follow cold or exposure; it occurs also in tetanus and other
convulsive diseases, and haemorrhage may be associated with tumors, with
syringomyelia or myelitis. A direct injury to the spine, however, from
blows or from falls, is by far the most common cause. Thorburn was among
the first to point out that acute flexures of the neck, often without attendant
fracture or dislocation of the vertebrae, was a form of accident that most
commonly preceded these haemorrhages. The level of the lesion, for this
reason, is most frequently in the lower cervical region. Twelve cases of
this type have been seen during the past few years in Halsted's service.
Anatomical Condition. — The extent of the haemorrhage may vary from
a small focal extravasation to one which finds its way in columnar fashion
a considerable distance up and down the cord. The bleeding primarily
takes place into the gray matter, and this as a rule suffers most, but the
surrounding medullated tracts may be thinned out and lacerated. In a
ease which occurred at the Montreal General Hospital under Wilkins the
hsemorrhage occupied a position opposite the region of the fifth and sixth
cervical nerves, and on transverse section the cord was occupied by a dark-red
clot measuring 12 by 5 mm., around which the white substance formed a
thin, ragged wall. The clot could be traced upward as far as the second
cervical, and downward as far as the fourth thoracic segment.
Symptoms. — Usually one side of the cord is involved much more than
the other, so that a type of the Brown- Sequard syndrome is very commonly
observed. The symptoms are sudden in onset, and leave the patient with
hyperaesthesia and a paralysis which becomes spastic and is most marked
on one side, while anaesthesia, chiefly to pain and temperature, are most
DIFFUSE AND FOCAL DISEASES OF THE SPINAL CORD. 937
marked on the opposite side of the body. Often a most distressing hyper-
sesthesia, usually a "pins and needles" sensation, may be present for
many days, but there is rarely any acute pain of the radiating or root
type. As hsematomyelia is most frequent in the lower cervical region, in
addition to the symptoms just mentioned a brachial type of palsy is commonly
seen, with flaccid and atrophic paralysis of the muscles innervated from
the lowest cervical and first thoracic segments. The haemorrhage may occur
in segments farther down the cord, the lumbar enlargement being affected
next in frequency to the lower cervical. The segmental level of the paralysis
necessarily would vary accordingly.
The condition may prove rapidly fatal, particularly if the extravasation
is bilateral and extends high enough in the cord to involve the centres for
the diaphragm. More frequently there is a more or less complete recovery
with a residual palsy of the upper extremity and a partial anaesthesia, corre-
sponding to the level of the lesion, and some spasticity of the leg.
Diagnosis. — The diagnosis of the traumatic cases is comparatively easy,
and it is important to recognize them, as they are often needlessly subjected
to operation under the belief that they are instances of acute compression.
The residual symptoms in old cases may closely simulate those seen in syringo-
myelia.
7. Caisson" Disease (Diver's Paralysis; Compressed Air Disease).
This remarkable affection, found in divers and in workers in caissons, is
characterized by a paraplegia, more rarely a general palsy, which supervenes
on returning from the compressed atmosphere to the surface.
The disease has been carefully studied by the French writers, by Leyden
and Schultze in Germany, and in America particularly by A. H. Smith.
It has been made the subject of a special monograph by Snell. The pressure
must be more than that of three atmospheres. The symptoms are especially
apt to come on if the change from the high to the ordinary atmospheric
pressure is quickly made. They may supervene immediately on leaving the
caisson, or they may be delayed for several hours. Pains of the most atrocious
character about the knees, elbows, or other joints, without swelling, as a rule,
pain and swelling in the muscles, epigastric pain, and vomiting are the most
common symptoms. Headache, giddiness, and paralysis are less frequent.
Paraplegia occurred in 15 per cent of Dr. Smith's cases and in 61 per cent
of the St. Louis cases. Monoplegia and hemiplegia are rare. In the most
extreme instances the attacks resemble apoplexy; the patient rapidly becomes
comatose and death occurs in a few hours. In the case of paraplegia the
outlook is usually good, and the paralysis may pass off in a day, or may con-
tinue for several weeks or even for months.
Several careful autopsies have been made. In Leyden's case death occurred
on the fifteenth day, and in the thoracic portion of the cord there were nu-
merous foci of ha?morrhage and signs of an acute myelitis. In Schultze's
case death occurred in two and a half months, and a disseminated myelitis
was found in the thoracic region. In both cases there were fissures, and ap-
pearances as if tissue had been lacerated. In a case examined on the third
day Assuring and laceration were found, and this condition has been deter-
mined by Boycott to be the esseuticil lesion in experimental anilMls, Jt lam
938 DISEASES OF THE NERVOUS SYSTEM.
been suggested that the symptoms are due to the liberation in the spinal cord
of bubbles of nitrogen which have been absorbed by the blood under the high
pressure, and the condition found at the autopsies just referred to is held to
favor this view.
Death is rare; it occurred in 12 of 76 cases at the St. Louis bridge, in
3 of the 110 cases at the Brooklyn bridge. In the important work on the
Firth of Forth bridge and the Blackvell tunnel there were no fatalities from
this cause.
The most successful treatment is recompression. A medical air lock should
be provided at the works, well heated and filled with bunks, etc. The recom-
pression stops the pain and relieves the symptoms. Morphia may be required.
III. COMPRESSION OF THE SPINAL CORD.
(Compression Myelitis.)
Definition. — Interruption of the functions of the cord by slow compression.
Etiology. — Caries of the spine, new growths, aneurism, and parasites are
the important causes of slow compression. Caries, or Pott's disease, as it is
usually called, after the surgeon who first described it, is in the great majority
of instances a tuberculous affection. In a few cases it is due- to s}'philis and
occasionally to extension of disease from the phar^mx. It is most common in
early life, but may occur after middle age. It follows trauma in a few cases.
Compression occasionally results from aneurism of the thoracic aorta or the
abdominal aorta, in the neighborhood of the cceliac axis. Malignant growtTis
frequently cause a compression paraplegia. A retroperitoneal sarcoma or
the lymphadenomatous growths of Hodgkin's disease may invade the vertebrse.
More commonly, however, the involvement is secondary to scirrhus of the
breast. Of parasites, the echinococcus and the cysticercus occasionally occur
in the spinal canal.
Symptoms. — These may be considered as they affect the bones, the nerves,
and the cord.
(1) Yeetebeal. — In malignant diseases and in aneurism, erosion of the
bodies may take place without producing any deformity of the spine. Fatal
haemorrhage may follow erosion of the vertebral artery. In caries, on the
other hand, it is the rule to find more or less deformity, amounting often to
angular curvature. The compression of the cord, however, is rarely if ever
the direct result of this bony kj-phosis but is due to the thickening of the dura
and the presence of caseous and inflammatory products between this mem-
brane and the bodies of the diseased vertebras. The spinous processes of the
affected vertebrae are tender on pressure, and pain follows jarring movements
or twisting of the spine. There may be extensive tuberculous disease without
much deformit}", particularly in the cervical region. In the case of aneurism
or tumor pain is a constant and agonizing feature.
(2) JSTerve-eoot Symptoms. — These result from compression of the nerve
roots as they pass out between the vertebrae. In caries, even when the disease
is extensive and the deformity great, radiating pains from compression involve-
ment of the roots are rare. Pains are more common in cancer of the spine
secondary to that of the breast, and in such cases may be agonizing. There
DIFFUSE AND FOCAL DISEASES OF THE SPINAL CORD. 939
may be acutely painful areas — the ancestliesia dolorosa — in regions of the skin
which are anaesthetic to tactile and painful impressions. Trophic disturb-
ances may occur, particularly herpes. Pressure on the ventral roots may give
rise to wasting of the muscles supplied by the affected nerves. This is most
noticeable in disease of the cervical or lumbar regions.
(3) Cord Symptoms. — (a) Cervical Region. — Not infrequently the caries
is high up between the axis and the atlas or between the latter and the oc-
cipital bone. In such instances a retropharyngeal abscess may be present,
giving rise to difficulty in swallowing. There may be spasm of the cervical
muscles, the head may be fixed, and movements may either be impossible
or cause great pain. In a case of this kind in the Montreal General Hos-
pital movement was liable to be followed by transient, instantaneous paraly-
sis of all four extremities, owing to compression of the cord. In one of these
attacks the patient died.
In the lower cervical region there may be signs of interference with the
cilio-spinal centre and dilatation of the pupils. Occasionally there is flushing
of the face and ear of one side or unilateral sweating. Deformity is not
so common, but healing may take place with the production of a callus
of enormous breadth, with complete rigidity of the neck.
(&) Thoracic Region. — The deformity is here more marked and pressure
symptoms are more common. The time of onset of the paralysis varies
very much. It may be an early symptom, even before the curvature is
manifest, and it is noteworthy that Pott first described the disease that
bears his name as '' a palsy of the lower limbs which is frequently found
to accompany a curvature of the spine.'' More commonly the paralysis is
late, occurring many months after the curvature has developed. The para-
plegia is slow in its development; the patient at first feels weak in the
legs or has disturbance of sensation, numbness, tingling, pins and needles.
The girdle sensation may be marked, or severe pains in the course of the
intercostal nerves. Motion is, as a rule, more quickly lost than sensation.
The paraplegia is usually of the spastic type, with exaggeration of the reflexes.
Bastian's symptom — abolition of the reflexes — is rarely met with in compres-
sion from caries as the transverse nature of the lesion is rarely complete. The
paraplegia may persist for months, or even for more than a year, and recovery
still be possible.
(c) Lumbar Region. — In the lower dorsal and lumbar regions the symp-
toms are practically the same, but the sphincter centres are involved and
the reflexes are not exaggerated.
Diagnosis. — Caries is by far the most frequent cause of slow compression
of the cord, and when there are external signs the recognition is easy. There
are cases in which the exudation in the spinal canal between the dura and
the bone leads to compression before there are any signs of caries, and if
the root symptoms are absent it may be extremely difficult to arrive at a
diagnosis. Janeway has called attention to persistent lumbago as a symptom
of importance in masked Pott's disease, particularly after injury. Brown-
Sequard's paralysis is more common in tumor and in injuries than in caries.
Pressure on the nerve roots, too, is less frequent in caries than in malignant
disease. The cervical form of pachymeningitis also produces a pressure
paralysis, the symptoms of which have already been detailed. Pressure from
940 DISEASES OF THE NERVOUS SYSTEM.
secondary carcinoma is naturall}' suggested when spinal symptoms follow
within a few years after an operation for cancer of the breast. In paraplegia
following tumor of the vertebra secondary to cancer of the breast^ and in
the erosion of the spine by retroperitoneal growths, the suffering is most
intense. The condition has been well termed paraplegia dolorosa. I have
seen two cases in which the breast tumor had not been recognized.
Treatment. — In compression by aneurism or metastatic tumors the con-
dition is hopeless. In the former the pains are often not very severe, but
in the latter morphia is always necessary. On the other hand, compression
by caries is often successfully relieved even after the paralysis has persisted
for a long period. When caries is recognized early, rest and support to
the spine by the various methods now used by surgeons may do much to
prevent the onset of paraplegia. When paralysis has developed, rest with
extension gives the best hope of recovery. It is to be remembered that
restoration may occur after compression of the cord has lasted for many
months, or even more than a year. Cases have been cured by recumbency
alone, enforced for weeks or months; the extradural and inflammatory
products are absorbed and the caries heals. In earlier days brilliant results
were obtained in these cases by suspension, a method introduced by J. K.
Mitchell in 1826, and pursued with remarkable success by his son, Weir Mitchell.
During my association with the Infirmary for Xervous Diseases I had numerous
opportunities of witnessing the really remarkable effects of persistent sus-
pension, even in apparently desperate and protracted cases. In recent years
the suspension methods in the erect posture have been largely superseded
by those of hyperextension during recumbency with the application of plaster
jackets to hold the body and spine immovable in the improved position.
Forcible correction of the deformity under anaesthesia as sometimes advo-
cated is not to be recommended; but the gentler partial corrections, perhaps
repeated several times with a few weeks' interval, often lead to a rapid disap-
pearance of paralyses through the lessening of the angular deformity of the
vertebra. In protracted cases after these methods have been given a fair
trial, laminectomy may become advisable, and has in many instances been
successful in relieving paralyses when bloodless methods have failed.
The general treatment of caries is that of tuberculosis — fresh air, good
food, cod-liver oil, and arsenic.
Lesioxs of the Cauda Equina akd Conus Medullaeis.
The spinal cord extends only to the second lumbar vertebra. Injury,
tumors, and caries at or below this level involve not the cord itself, but the
bundle of nerves known as the cauda equina and the terminal portion of
the cord, the conns medullaris. Much attention has been given to lesions
of this part. The whole subject is admirably discussed in Thorburn's work.
Fractures and dislocations are common in the lumbo-sacral region, tumors
not infrequently involve the filaments of the cauda equina, and some of
the nerves are often entangled in the cicatrix of a spina bifida.
A lesion limited to the conus medullaris is rare. A myelitis or a focal
hgematomyelia may be limited to this site with symptoms referable to a
lesion of the lowest sacral segments — anaesthesia over the buttocks, perinaeum,
and genitalia, paralysis of the levator ani and the vesical and anal sphincters.
DIFFUSE AND FOCAL DISEASES OF THE SPINAL CORD. 941
Such a focalized lesion has heen known to follow a lumbar puncture made
between the first and second lumbar vertebraj.
In a fracture or dislocation of the first lumbar vertebra the conus medul-
laris may be compressed together with the lowest sacral nerves given ofE
from it. It is rare, however^ in traumatic cases for the tip of the cord to
suffer injury alone without simultaneous involvement of the nerve roots com-
])rising the cauda equina from the second lumbar down. In fracture or
dislocation of the fifth lumbar vertebra the sacral roots may alone be involved.
Thus in a case which I have reported the patient fell from a bridge and
had paralysis of the legs and of the bladder and rectum. When seen sixteen
years after the injury, there was slight weakness, with wasting of the left
leg; there w-as complete loss of the function in the ano-vesical and genital
centres, and anaesthesia in a strip at the back part of the thigh (in the
distribution of the small sciatic), and of the perinsum, scrotum, and penis.
The urethra was also insensitive.
It is sometimes very difficult to differentiate between a lesion, possibly
at the first lumbar vertebra, involving the lower part of the spinal cord
and one in the sacral region which compromises those peripheral nerves of the
Cauda equina that are given off from the same segment. This is particu-
larly so in the case of tumors, for in fractures or caries there may be some
palpable indication of the seat of trouble. In cauda equina lesions, however,
pressure upon the nerve roots is supposed to affect motion much more markedly
than sensation, and this discrepancy may be helpful since in the cord lesions
themselves the motor and sensory disturbances are more apt to have a corre-
spondingly segmental distribution.
The table and figures given in the general introduction wall be found
useful in determining the nerve fibres and segments involved in these cases
of injury of the cauda equina.
IV. TUMORS OF THE SPINAL CORD AND ITS
MEMBRANES.
Morbid Anatomy. — Xew^ growths may develop in the cord or in its mem-
branes, or may extend into them from the spine. These invading growths
are the more common and have been touched upon in a previous section.
Here the primary spinal growths onty wall be considered.
■ Schlesingers tabulation in 1898 of 400 cases shows that meningeal tumors
are considerably more common than medullary or true cord tumors. Solitary
tubercles are b}' far the most frequent medullary growths. The meningeal
tumors may be either intra- or extradural and the intradural sarcomata
or fibromata — it is often difficult to tell under which of these terms they
should be classified — are by far the most common. This is important because
these particular growths remain for a long time non-infiltrating and offer
most favorable opportunities for surgical treatment. In the extradural space
echinococcus cysts are in some countries frequently found. They are usually
multiple, and indeed, most of the other forms of tumor may be multiple. A
lipoma, psammoma, myxoma, neuroma, and other varieties of growth may
be met mth. Gummata and gliosarcomata are not infrequent and usually
involve both the cord and the meninges.
942 DISEASES OF THE NERVOUS SYSTEM.
Tumors are more commonly situated on the lateral and dorsal surfaces
of the cord, but there is no level of the spine in which they may not occur.
The effects of tumor on the functions of the cord are varied. Slow com-
pression is usuall}'^ produced by growths external to the cord, and it is remark-
able what a high grade of compression the cord will bear without serious inter-
ference with its functions. In cases of prolonged interruption of function
ascending and descending degenerations occur. Tumors developing within the
cord may lead to syringomyelia.
Symptoms. — These will naturally vary a good deal with the segment in-
volved and with the degree of pressure and the extent of implication of the
nerve roots. Xeuralgic pains which persist over a particular territory, and a
slowly progressive paralysis which may at iirst suggest a Bro-^Ti-Sequard
s}"iidrome, should always make one suspect a spinal growth.
The symptoms of the commoner intradural tumors are as follows : Eadiat-
ing (root) pains from the level of the lesion; segmental atrophy from pressure
on the ventral horns; weakness of the leg, going on to paralj'sis, at first only
on the side occupied by the growth, and due to pyramidal tract involvement;
sensory disturbances on the opposite side, first affecting pain and temperature
sense; with increase of symptoms the crossed type of paralysis is lost and motor
palsy occurs on both sides with great increase of reflexes; even in advanced
cases the sensory paratysis rarely becomes quite complete, since some tactual
transmission from the lower sacral segments usually persists ; spasmodic, pain-
ful, jerking movements of the lower extremities are ver}' characteristic of the
advanced cases. These sj-mptoms will vary naturally with the character of
the growth, its segmental level, place of origin, and other factors, but in no
other disease is there the same coincidence of a gradual compression paraplegia
and persistent radiating pain. In some cases pain may be elicited by deep
pressure alongside the spinous processes at the level of the growth, and the
patient, b}* sudden exertion, or by straining, coughing, or sneezing, may greatly
increase it.
Diagnosis. — Wlien constant and severe root pains are associated with a
progressive parah'sis, the diagnosis may be easily made. Caries may cause
identical symptoms, but the radiating pains are rarely so severe. Cervical
meningitis simulates tumor very closely, and in realit}^ produces identical
effects, but the very slow progress and the bilateral character from the outset
may be sufficient to distinguish it. In chronic transverse myelitis the s3Tnp-
toms, according to Gowers, may resemble tumor very closely and present radi-
ating pains, a sense of constriction, and progressive paralysis. S}Tingomyelia,
too, may give a similar picture, A radiogram may be of diagnostic aid in
case the vertebrse are infiltrated by the growth.
The nature of the tumor can rarely be indicated with precision. With a
marked sj'philitic histor}' gumma may naturally be suspected, or vrith coex-
isting tuberculous disease, a solitary tubercle.
Treatment. — If the possibility of syphilitic infection is present the iodide
of potassium should be given in large and increasing doses. For the severe
pains counter-irritation is sometimes beneficial, particularly the thermo-
cautery; morphia is, however, often necessary. A successful laminectomy
offers the only hope of relief in case the lesion prove to be non-syphilitic.
During the seventeen years since Horsley's first brilliant operation there haye
DIFFUSE AND FOCAL DISEASES OF THE SPINAL CORD. 943
been numerous cases of successful extirpation of spinal cord tumors. The
intradural fibrosarcomata are the most favorable cases and complete restora-
tion of function in the cord may follow the removal of the tumor. In the
infiltrating growths the nerve roots may be divided, or, as has been suggested,
even the cord itself sectioned for the relief of the agonizing pain, but ultimate
cure is hopeless in malignant growths of this character.
V. SYRINGOMYELIA.
Definition. — A gliomatous new growth about the central canal of the spinal
cord, with cavity formation.
Etiology and Morbid Anatomy. — Syringomyelia must be distinguished
from dilatation of the central canal — hydromyelus — slight grades of which are
not very uncommon either as a congenital condition or as a result of the
pressure of tumors. The cavity of syringomyelia has a variable extent in the
cord, sometimes running the entire length, but in many cases involving only
the cervical and thoracic regions or a more limited area. It is usually in the
dorsal portion of the cord and may extend only into one dorsal cornu. The
transverse section may be oval or circular or narrow and fissure-like. It varies
at different levels. The condition is now regarded as a gliosis, a development
of embryonal neurogliar tissue in which hsemorrhage or degeneration takes
place with the formation of cavities.
Of 190 cases, 133 were in men, 57 in women' (Schlesinger). A large
majority of the cases begin before the thirtieth year. The disease has been
met with in three members of the same family.
Symptoms. — The clinical features are extremely complex. In the classical
form there are irregular pains, chiefly in the cervical region ; muscular atroph}''
develops, which may be confined to the arms, or sometimes extends to the legs.
The reflexes are increased and a spastic condition develops in the legs. Ulti-
mately the clinical picture may be that of an amyotrophic lateral sclerosis. The
tactile sensation is usually normal and the muscular sense is retained, but pain-
ful and thermic sensations are not recognized, or there may be in rare instances
complete angesthesia of the skin and of the mucous membranes (Dejerine).
This combination of loss of painful and thermic sensations with paralysis of
an amyotrophic type is characteristic, but not pathognomonic of the disease.
The special senses are usually intact and the sphincters uninvolved. Trophic
troubles are not uncommon. Owing to the loss of the pain and heat sensations,
the patients are apt to injure themselves. Scoliosis also may be present in
these cases. The loss of painful and thermic impressions is due to the fact
that these pass to the brain in the peri-ependymal gray matter, particularly
that portion in the dorsal roots, which is almost constantly involved in syringo-
myelia. The tactile sensation is retained because the postero-lateral columns
are uninvolved.
Schlesinger, in his monograph (1895), recognizes the following types:
(1) With the classical features above described, which may begin in the
cervical or lumbar regions; (3) a motor type, with the picture of an amyo-
trophic or a spastic paralysis — the sensation may be undisturbed for years;
(3) with predominant sensory features, simulating hysterical hemiplegia, or
with general pain and temperature anaesthesia; (4) with pronounced trophic
944 DISEASES OF THE NERVOUS SYSTEM.
disturbances — to this type belong the cases described as Morvan's disease, an
afEection characterized by neuralgic pains, cutaneous anaesthesia, and painless,
destructive whitlows; and (5) the tabetic type, either a combination of the
symptoms of tabes in the lower, and of syringomyelia in the upper extremities,
or a pure tabetic symptom-complex, due to invasion of the dorsal columns by
the gliosis (Oppenheim). Arthropathies occur in about 10 per cent of the
cases.
Diagnosis. — In typical cases the diagnosis is easy. The combination of an
amyotrophic paralysis, the picture of progressive muscular atrophy of the
Aran-Duchenne type, with retention of tactile and loss of thermic and painful
sensation, is probably pathognomonic of the disease. Of affections with which
it may be confounded, anaesthetic leprosy is the most important, since the
anaesthesia and the wasting may closely simulate it; but, as a rule, in leprosy
trophic changes are more or less marked. There is often loss of phalanges
and there is no characteristic dissociation of sensory impressions.
VI. ACUTE MYELITIS.
Etiology. — Acute myelitis results from many causes, and may affect the
cord in a limited or extended jDortion — the gray matter chiefly, or the gray
and white matter together. It is met with: (a) As an independent affection
following exposure to cold, or exertion, and leading to rapid loss of power
with the symptoms of an acute ascending paralysis, (h) As a sequel of the
infectious diseases, such as small-pox, typhus, measles, and gonorrhoea, (c) As
a result of traumatism, either fracture of the spine or very severe muscular
effort. Concussion without fracture may produce it, but this is rare. Acute
myelitis, for instance, sca,rcely ever follows railway accidents, (d) In diseases
of the bones of the spine, either caries or cancer. This is a more common cause
of localized acute transverse myelitis than of the diffuse affection, (e) In
disease of the cord itself, such as tumors and syphilis; in the latter, either in
association with gummata, in which case it is usually a late manifestation ; or
it may follow within a year or eighteen months of the primary affection.
Morbid Anatomy. — In localized acute myelitis affecting white and gray
matter, as met with after accident or an acute compression, the cord is swollen,
the pia injected, the consistence greatly reduced, and on incising the mem-
brane an almost diffluent material may escape. In less intense grades, on section
at the affected area, the distinction between the gray and white matter is lost,
or is extremely indistinct. The tissue may be injected, or, as is often the case,
haemorrhagic. It is particularly in these forms, due to extension of disease
from without or to acute compression, that we find definite involvement of
the white matter. In other instances the gray matter is chiefly affected. There
may be localized areas throughout the cord in which the gray matter is reduced
in consistence and haemorrhagic, the so-called red softening. There may be
definite cavity formations in these foci. In some cases of disseminated or
focal myelitis the meninges also are involved and there is a myelomeningitis.
And, lastly, there are instances in which, throughout a long section of the
cord, sometimes through the lumbar and the greater part of the thoracic, or
in the thoracic and cervical regions, there is a diffuse myelitis of the gray
DIFFUSE AND FOCAL DISEASES OF THE SPINAL CORD. 945
Histologically the nerve fibres are much swollen and irregularly distorted,
the axis-cylinders are beaded, the myelin droplets are abundant, and the
laminated bodies known as corpora amylacea may be seen. Granular fatty
cells are also numerous and there may be leucocytes and red blood-corpuscles.
Changes in the blood-vessels are striking; the smaller veins are distended and
may show varicosities. The perivascular lymph spaces contain numerous leu-
cocytes, and the smaller arteries themselves are frequently the seat of hyaline
thrombi. The ganglion cells are swollen and irregular in outline, the proto-
plasm is extremely granular and vacuolated, and the nuclei, though usually
invisible, may show signs of division, and the processes of the cells are not seen.
In cases which persist for some time we have an opportunity of seeing
the later stages of acute myelitis. The acute, inflammatory, hypersemic or
red softening is succeeded by stages in which the affected area becomes
more yellow from gradual alteration of the blood-pigment, and finally white
in color from the advancing fatty degeneration. In cases of compression
myelitis, a sclerosis may gradually be produced with the anatomical picture
of a chronic diffuse myelitis.
Symptoms, — (a) Acute Diffuse Myelitis. — This form may follow ex-
posure to cold, or occurs in connection with syphilis or one of the infectious
diseases, or is seen in a typical manner in the extension from injuries or
from tumor. The onset, though scarcely so abrupt as in hsemorrhage, may
be sudden; a person may be attacked on the street and have difficulty in
getting home. In some instances, the onset is preceded by pains in the
legs or back, or a girdle sensation is present. It may be marked by chills,
occasionally by convulsions; fever is usually present from the beginning —
at first sight, but subsequently it may become high.
The motor functions are rapidly lost, sometimes as quickly as in Landry's
ascending paralysis. The paraplegia may be complete, and, if the myelitis
extends to the cervical region, there may be impairment of motion, and
ultimately complete loss of power in the upper extremities as well. The
sensation is lost, but there may at first be hypersesthesia. The reflexes in
the initial stage are increased, but in acute central myelitis, unless limited
in extent to the thoracic and cervical regions, the reflexes are usually abolished.
The rectum and bladder are paralyzed. Trophic disturbances are marked;
the muscles waste rapidly; the skin is often congested, and there may be
localized sweating. The temperature of the affected limbs may be lowered.
Acute bed-sores may develop over the sacrum or on the heels, and sometimes
a multiple arthritis is present. In these acute cases the general symptoms
become greatly aggravated, the pulse is rapid, the tongue becomes dry ; there
is delirium, the fever increases, and may reach 107° or 108°.
The course of the disease is variable. In very acute cases death follows
in from. five to ten days. The cases following the infectious diseases, par-
ticularly the fevers and sometimes syphilis, may run a milder course.
The diagnosis of this variety of acute myelitis is rarely difficult. In
common with the acute ascending paralysis of Landry, and with certain
cases of multiple neuritis, it presents a rapid and progressive motor paraly-
sis. From the former it- is distinguished by the more marked involvement
of sensation, the trophic disturbances, the paralysis of bladder and rectum,
the rapid wasting, the electrical changes, and the fever. From acute cases
61
946 DISEASES OF THE NERVOUS SYSTEM,
of multiple neuritis it may be more difficult to distinguish, as the sensory
features in these eases may be marked, though there is rarely, if ever, in
multiple neuritis complete anaesthesia; the wasting, moreover, is more rapid
in myelitis. The bladder and rectum are rarely involved — though in ex-
ceptional cases they may be — and, most important of all, the trophic changes,
the development of bullae, bed-sores, etc., are not seen in multiple neuritis.
(&) Acute Traxsverse Myelitis. — The symptoms naturally differ with
the situation of the lesion.
(1) Acute transverse myelitis in the ilioracic region, the most common
situation, produces a very characteristic picture. The sjToptoms of onset
are variable. There may be initial pains or numbness and tingling in the
legs. The paralysis may set in quickly and become complete within a
few days; but more commonly it is preceded for a day or two by sensations
of pain, heaviness, and dragging in the legs. The paralysis of the lower
limbs is usually complete, and if at the level, say, of the sixth thoracic
vertebra, the abdominal muscles are involved. Sensation may be partially
or completely lost. At the onset there may be numbness, tingling, or even
h3'per8esthesia in the legs. At the level of the lesion there is often a zone of
hyperassthesia, which is discovered by passing a test-tube containing hot
water along the spine, when the sensation of warmth changes to one of
actual pain, A girdle sensation may occur early, and when the lesion is in
this situation it is usually felt between the ensiform and umbilical regions.
The reflex functions are variable. There may at first be abolition of the
reflexes; subsequently, those which pass through the segments lower than the
one affected, may be exaggerated and the legs may take on a condition of spastic
rigidity. It does not always happen, however, that the reflexes are increased
here, for in a total transverse lesion of the cord, they are usually entirely lost,
as first pointed out b}^ Bastian. That this is not due to the preliminary shock
is shown by the fact that the abolition of the reflexes may be permanent. The
muscles become extremely flabby, waste, and lose their faradic excitability, and
the sphincters lose their tone. The temperature of the paralyzed limbs is vari-
able. It may at first rise, then fall and become subnormal. Lesions of the skin
are not uncommon, and bed-sores are apt to form. There is at first retention of
urine and subsequently spastic incontinence. If the lumbar centres are in-
volved, there are from the outset vesical symptoms. The urine is alkaline in
reaction and may rapidly become ammoniacal. The bowels are constipated
and there is usually incontinence of the faeces. Some writers attribute the cys-
titis associated with transverse myelitis to disturbed trophic influence.
The course of complete transverse myelitis depends a good deal upon its
cau5e. Death may result from extension. Segments of the cord may be com-
pletely and permanently destroyed, in which case there is persistent paraplegia.
The pyramidal fibres below the lesion undergo the secondary degeneration, and
there is an ascending degeneration of the dorsal median columns. If the
lower segments of the cord are involved the legs may remain flaccid. In some
instances a transverse myelitis of the thoracic region involves the ventral horns
above and below the lesion, producing flaccidity of the muscles, with wasting,
fibrillar contractions, and the reaction of degeneration. More commonly,
however, in the cases which last many months there is more or less rigidity of
the muscles with spasm or persistent contraction of the flexors of the knee.
DIFFUSE AND FOCAL DISEASES OF THE BRAIN. 947
(2) Transverse Myelitis of the Cervical Region. — If the lesion is at the
level of the sixth or seventh cervical nerves, there is paralysis of the upper
extremities, more or less complete, sometimes sparing the muscles of the
shoulder. Gradually there is loss of sensation. The paralysis is usually com-
plete below the point of lesion, but there are rare instances in which the arms
only are affected, the so-called cervical paraplegia. In addition to the symp-
toms already mentioned there are several which are more characteristic of
transverse myelitis in the cervical region, such as the occurrence of vomiting,
hiccough, and slow pulse, which may sink to 20 or 30, pupillary changes —
myosis — sometimes attacks of dysphagia, dyspnoea, or syncope.
Treatment of Acute Myelitis. — In the rapidly developing form due either
to a diffuse inflammation in the gray matter or to transverse myelitis, the
important measures are scrupulous cleanliness, care and watchfulness in
guarding against bed-sores, the avoidance of cystitis, either by systematic
catheterization or, if there is incontinence, by a carefully adjusted bed urinal,
or the use of antiseptic cotton-wool repeatedly changed. In an acute onset
in a healthy subject the spine may be cupped. Counter-irritation is of doubt-
ful advantage. Chapman's ice-bag is sometimes useful. No drugs have the
slightest influence upon an acute myelitis, and even in subjects with well-
marked syphilis neither mercury nor iodide of potassium is curative. Tonic
remedies, such as quinine, arsenic, and strychnia, may be used in the later
stages. When the muscles have wasted, massage is beneficial in maintaining
their nutrition. Electricity should not be used in the early stages of myelitis.
It is of no value in the transverse myelitis in the thoracic region with retention
of the nutrition in the muscles of the leg.
E. DIFFUSE AND FOCAL DISEASES OF THE BRAIN.
I. TOPICAL DIAGNOSIS.
Only certain regions of the brain give localizing symptoms. These are the
cortical motor centres and the associated sensory centres, the speech centres,
the centres for the special senses, and the tracts which connect these cortical
areas with each other and with other parts of the nervous system.
The following is a brief summary of the effects of lesions from the cortex
to the spinal cord :
1. The Cerebral Cortex. — {a) Destructive lesions of the motor cortex cause
paralysis in the muscles of the opposite side of the body. The paralysis is at
first flaccid, but the spastic condition subsequently develops. The extent of
the paralysis depends upon that of the lesion. It is apt to be limited to the
muscles of the head or of an extremity, giving rise to the cerebral monoplegias.
One group of muscles may be much more affected than others, especially in
lesions of the highly differentiated area for the upper extremity. It is un-
common to find all the muscle groups of an extremity equally involved in
cortical monoplegia. Very rarely through small bilaterally symmetrical lesions
monoplegia -of the tongue may result without paralysis of the face. A lesion
may involve centres lying close together or overlapping one another, thus pro-
ducing associated monoplegias — e. g., paralysis of the face and arm, or of the
948 DISEASES OF THE NERVOUS SYSTEM.
arm and leg, but not of the face and leg without involvement of the arm.
Very rarely the whole motor cortex is involved, causing paralysis of the opposite
side — cortical hemiplegia. Usually in such instances there is marked recovery,
so that only a monoplegia persists.
Adjoining and posterior to the motor area is believed to be the region of
the cortex in which the impulses concerned in general bodily sensation (cutane-
ous sensibility, muscle sense, visceral sensations) first arrive (the somaesthetic
area). Combined with the muscular weakness there is usually some disturb-
ance of sensations, particularly of those of the muscular sense. In lesions of
the superior parietal lobe the stereognostic sense is very often affected. For
example, when a coin or a knife is placed in the hand of the affected limb, the
patient's eyes being closed, it is not recognized, owing to inappreciation of
the form and consistence of the object, and this even though the slightest
tactile stimulus applied to the fingers or surface of the hand is felt and may
be correctly localized. The sense of touch, pain, and temperature may be
lowered, but usually not markedly unless the superior and inferior parietal
lobules are involved in subcortical lesions. Parsesthesias and vaso-motor dis-
turbances are common accompaniments of paralyses of cortical origin.
(6) Irritative lesions cause localized spasms as described on page 883.
The most varied muscle groups corresponding to particular movement forms
may be picked out. If the irritation be sudden and severe, typical attacks of
Jacksonian epilepsy may occur. These convulsions are often preceded and
accompanied by subjective sensory impressions. Tingling or pain, or a sense
of motion in the part, is often the signal symptom (Seguin), and is of great
importance in determining the seat of the lesion.
Lesions are often both destructive and irritative, and we then have com-
binations of the symptoms produced by each. For instance, certain muscles
may be paralyzed, and those represented near them in the cortex may be the
seat of localized convulsions, or the paralyzed limb itself may be at times
subject to convulsive spasms, or muscles which have been convulsed may be-
come paralyzed. The close observation of the sequence of the symptoms in
such cases often makes it possible to trace the progress of a lesion involving
the motor cortex. In these cases the most frequent cause is a developing tumor,
though sometimes local thickenings of the membranes of the brain, small ab-
scesses, minute heemorrhages, or fragments of a fractured skull must be held
responsible.
In another section lesions involving the centres for the special senses are
considered, and we shall simpl}'' refer to them here. The symptoms caused
by lesions of the speech centres will be described under aphasia, and it is
only necessary to note here the near situation of the motor speech area (Broca's
centre) in the left inferior frontal convolution to the centres for the face and
tongue on that side, and the nearness of the supposed centre for writing to
that of the hand and arm, and to state that motor aphasia is often associated
with paralysis of the right side of the face and the right arm. Accompanying
the paralysis, following a Jacksonian fit, of the right face or arm there is often
a transient motor aphasia.
According to Flechsig, the sensori-motor centres are limited to tolerably
circumscribed areas in the cortex, which differ from other portions in that they
are provided with projection fibres which connect them with lower centres.
DIFFUSE AND FOCAL DISEASES OF THE BRAIN. 949
The remaining areas of the cortex, amounting, he believes, to about two-thirds
of the whole, are devoid of projection fibres and are concerned entirely in
associative activities. These latter areas, the " association centres " of Flech-
sig, are three in number: (1) The anterior association centre, including the
whole of the frontal lobe in front of the somgesthetic area; (2) the middle
association centre, corresponding to the cortex of the island of Eeil; and (3)
the large, posterior association centre, including the prsecuneus, the superior
and inferior parietal lobules, the supramarginal and angular gyri, and the
whole of the temporal and occipital lobes except the auditory and visual sen-
sory areas.
Flechsig attributes the higher psychic functions, especially those connected
with the personality of the individual, to the anterior association centres, while
the intellectual activities which have to do with knowledge of the external
world he believes correspond to the functions of the large posterior association
centre. Whether these views be true, and, if so, in how far they may be applied
practically in the localization of diseases, especially of the mind, the future
has to decide.
2. Centrum Semiovale. — Lesions in this part may involve either projection
fibres (motor or sensory) or association fibres. If involvement of the motor
path cause paralysis, this has the distribution of a cortical palsy when the
lesion is near the cortex, and of a paralysis due to a lesion of the internal
capsule when it is near that region. These lesions of the motor fibres may
be associated with symptoms due to interruption in the other systems of fibres
running in the centrum semiovale ; there may be sensory disturbances — hemi-
anesthesia and hemianopia — and if the lesion is in the left hemisphere one
of the different forms of aphasia may accompany the paralysis.
3. Corpus Callosum. — This may be congenitally absent without symptoms.
An acute lesion involving a large portion of the corpus callosum may, how-
ever, yield symptoms suggestive of its localization in this region. In the case
recorded by Reinhard, in which the situation of the lesion was suspected ante
mortem, there was a disturbance of equilibration (without vertigo) and of
the synergetic movements of both halves of the body. The autopsy revealed
a gliosarcoma which had destroyed the posterior three-fourths of the corpus
callosum. In Bristowe's 4 cases there existed, as symptoms common to all,
pain in the head and partial or complete hemiplegia, with gradual extension
of the paralysis to the opposite side of the body. Toward the end of life there
was disturbance of speech, difficulty in deglutition, incontinence of urine and
fasces, and dementia. Here the symptoms have in them nothing that can be
looked upon as pathognomonic ; indeed, many of the phenomena were doubtless
dependent upon involvement of the projection and association fibres of the
centrum semiovale.
In animals in which the corpus callosum has been cut experimentally pro-
gressive emaciation has been mentioned as a characteristic phenomenon.
4. Internal Capsule (Fig. 4). — Through this pass within a rather narrow
area all, or nearly all, of the projection fibres (both motor and sensory) which
are connected with the cerebral cortex. It is divided into an anterior limb, a
knee, and a posterior limb, the latter consisting of a thalamo-lenticular por-
tion (its anterior two-thirds) and a retro-lenticular portion (its posterior
third). In considering the effects of a given focal lesion involving the fibres
950 DISEASES OF THE NERVOUS SYSTEM.
of the internal capsule, it is not to be forgotten that the relations of the two
limbs of the capsule to one another and to the knee vary considerably in dif-
ferent horizontal planes. Much of the confusion in the bibliography is de-
pendent upon neglect to describe the horizontal level of the lesion, as well as
its situation in an antero-posterior direction. The principal bundle passing
through the anterior limb of the capsule is that which connects the frontal gyri
and the medial bundle in the base of the peduncle (crus) with the nuclei of
the pons. These fibres are centrifugal, and innervate chiefly the lower motor
nuclei governing bilaterally innervated muscles, especially those of the eyes,
head, neck, and probably those of the mouth, tongue, and larynx. In lower
horizontal planes these fibres are situated near the knee of the capsule. It is
the region of the knee of the capsule which transmits especially the fibres pass-
ing from the cerebral cortex to the nuclei of the facial, hypoglossal, and third
nerves. ' The path which supplies the nuclei governing the muscles used in
speech passes through the knee.
The pyramidal tract goes through the thalamo-lenticular portion of the
capsule. The motor fibres are arranged according to definite muscle groups,
or rather movement forms, those for the movements of the arm being anterior
to those for the leg. The number of fibres for a given muscle group corre-
sponds rather to the degree of complexity of the movements than to the size
of the muscles concerned. Thus the areas for the fingers and toes are rela-
tively large.
The fibres to the somgesthetic area of the cortex — that is, those from the
ventro-lateral group of nuclei of the thalamus and the tegmental radiations —
carrying impulses concerned in general bodily sensation, pass upward through
the posterior part of the thalamo-lenticular portion of the capsule. Some of
these fibres pass through the anterior two-thirds of the posterior limb along-
side of the fibres of the pyramidal tract.
Through the retro-lenticular portion of the posterior limb, opposite the
posterior third of the lateral surface of the thalamus, pass ( 1 ) the fibres carry-
ing impulses concerned in the sensations of the opposite visual field (optic
radiation from the lateral geniculate body to the visual sense area in the
occipital cortex) ; (2) the fibres carrying impulses concerned in auditory sen-
sations (radiation from the medial geniculate body to the auditory sense area
in the cortex of the temporal lobe) ; (3) the fibres (probably centrifugal)
connecting the cortex of the temporal lobe with the nuclei of the pons.
With this preliminary knowledge concerning the internal capsule, it is not
difficult to understand the symptoms which result when it is diseased.
Since here all the fibres of the upper motor segment are gathered together
in a compact bundle, a lesion in this region is apt to cause complete hemi-
plegia of the opposite side, followed later by contractures; and if the lesion
involves the hinder portion of the posterior limb there is also hemiansesthesia,
including even the special senses (Fig. 4). As a rule, however, lesions of
the internal capsule do not involve the whole structure. The disease usually
affects mainly either the anterior or posterior portions, and even in instances
in which at first the symptoms point to total involvement, there is a disap-
pearance often of a large part of the phenomena after a short time. Thus
when the pyramidal tract is destroyed (lesion of the thalamo-lenticular por-
tion of the capsule) the arm may be affected more than the leg, or vice versa.
DIFFUSE AND FOCAL DISEASES OF THE BRAIN. 951
The facial paralysis is usually slight, though if the lesion be well forward
in the capsule the paralysis of the face and tongue may be marked.
Hemiansesthesia alone without involvement of the motor fibres, due to dis-
ease of the capsule, is rare. There is usually also at least partial paralysis
of the leg. When the retro-lenticular portion of the capsule is destroyed the
hemianaesthesia is accompanied by hemianopsia, disturbances of hearing, and
sometimes of smell and taste. The occurrence of hemichorea, marked tremor,
or hemiathetosis after a capsular hemiplegia points to the involvement of the
thalamus or of the hypothalamic region in the lesion.
Charcot and others have described cases in which as a result of disease of
the internal capsule there has been paralysis of the face and leg without
involvement of the arm. In such instances the lesion is linear, extending from
the posterior part of the anterior limb of the internal capsule backward and
lateralward to the leg region in the posterior limb of the capsule, the region
for the arm escaping.
Capsular lesions when pure are not usually accompanied by aphasic
symptoms, alexia, or agraphia. A " subcortical " motor aphasia may result
if the lesion is bilaterial, as in pseudo-bulbar paralysis, or if on the left
side it is so extensive as to destroy the fibres connecting Broca's convolu-
tion with the opposite hemispheres, as well as the pyramidal fibres on the
same side.
5. Crura (Cerebral Peduncles). — From this level through the pons, me-
dulla, and cord the upper and lower motor segments are represented, the first
by the fibres of the pyramidal tracts and by the fibres which go from the cere-
bral cortex to the nuclei of the cerebral nerves, the latter by the motor nuclei
and the nerve fibres arising from them. Lesions often affect both motor
segments, and produce paralyses having the characteristics of each. Thus a
single lesion may involve the pyramidal tract and cause a spastic paralysis
on the opposite side of the body, and also involve the nucleus or the fibres
of one of the cerebral nerves, and so produce a lower segment paralysis on
the same side as the lesion — crossed paralysis. In the crus the third and
fourth cerebral nerves run near the pyramidal tract, and a lesion of this region
is apt to involve them or their nuclei, causing partial paralysis of the muscles
of the eye on the same side as the lesions, combined with a hemiplegia of the
opposite side (Fig. 1, 3).
The optic tract also crosses the crus and may be involved, giving hemi-
anopsia in the opposite halves of the visual fields.
If the tegmentum be the seat of a lesion which does not involve the base
of the peduncle (or pes) there may be disturbances of cutaneous and mus-
cular sensibility, ataxia, disturbances of hearing, or oculo-motor paralysis. An
oculo-motor paralysis of one side, accompanied by a hemi-ataxia of the opposite
side, appears to be especially characteristic of a tegmental lesion.
6. Corpora Quadrigemina. — Anatomical studies point to the view that the
superior colliculus (anterior quadrigeminal body) represents the most impor-
tant subcortical central organ for the control of the eye-muscle nuclei. This
is supported to a certain extent by clinical evidence, though as yet but few
cases have been carefully studied. Sight is only slightly, if at all, disturbed
when the superior colliculus is destroyed. The pupil is usually widened, and
the pupillary reaction, both to light and on accommodation, interfered with.
952 DISEASES OF THE NERVOUS SYSTEM.
Apparently actual paralysis of the eye muscles does not occur unless the nucleus
of the third nerve ventral to the aqueduct he also injured.
The inferior collicuTus (posterior quadrigeminal body), on the other hand,
has been shown by anatomical study to be an important way-station in the
auditory conduction-path. A large part of the lateral lemniscus ends in its
nucleus, and from it emerge medullated fibres which pass through the brachium
quadrigeminum inf erius to the medial geniculate body. Thence a large bundle
runs through the retro-lenticular portion of the internal capsule to the auditory
sense area in the cortex of the temporal lobe.
Weinland has collected 19 cases of tumors of the corpora quadrigemina
from the bibliography; in 9 of these auditory disturbances were especially
noted. Since the central auditory path of each side receives impulses from
both ears, lesion of the coUiculus on one side may dull the hearing on both
sides, though the opposite ear is usually the more defective. Lesion of the
inferior coUiculus may be accompanied by disturbance of mastication, owing
to paralysis of the descending (mesencephalic) root of the trigeminus. The
fourth nerve may also be involved. The ataxia which sometimes accompanies
lesions of the corpora quadrigemina is probabl}" to be referred to disturbance
in conduction in the medial lemniscus.
7. Pons and Medulla Oblongata. — Lesions involving the pyramidal tract,
together with any one of the motor cerebral nerves of this region, cause crossed
paralysis. A lesion in the lower part of the pons is apt to cause a lower-
segment paralysis of the face on the same side (destruction of the nucleus of
the facial nerve or of its root fibres) and a spastic paralysis of the arm and
leg on the opposite side (injury to pyramidal tract) (Fig. 1, 4). The abdu-
cens, the motor part of the trigeminus, and the hypoglossus nerves may also
be paralyzed in the same manner. When the central fibres to the nucleus
of the hypoglossus are involved a peculiar form of anarthria results. If the
nucleus itself be diseased, swallowing is interfered with.
When the sensory fibres of the fifth nerve are interrupted, together with
the sensor}' tract (the medial lemniscus or fillet) for the rest of the body, which
has already crossed the middle line, there is a crossed sensory paralysis —
i. e., disturbed sensation in the distribution of the fifth on the side of the
lesion, and of all the rest of the body on the opposite side.
A paralj'sis of the external rectus muscle of one eye and of the internal
rectus of the other eye (conjugate paralysis of the muscles which turn the
eyes to one side), in the absence of a "forced position" of the eyeballs, is
highly characteristic of certain lesions of the pons. In such cases the internal
rectus may still be capable of functioning on convergence, or when the eye
to which it belongs is tested independently of that in which the external rectus
is paralyzed. This form of paralysis is found, as a rule, only when the lesion
lies just in front of the abducens or involves the nucleus itself, or includes,
besides the root fibres of the abducens, that portion of the formatio reticularis
that lies between them and the fasciculus longitudinalis medialis (von Mona-
kow). The cases of conjugate paralysis just referred to may be complicated
by other disturbances of the eye-muscle movements, in which case the inter-
pretation of the symptoms may be rendered difficult. The facial nerve is often
involved in these paralyses.
In lesions of the pons the patient often has a tendency to fall toward the
DIFFUSE AND FOCAL DISEASES OF THE BRAIN. 953
side on which the lesion is, probably on account of implication of the middle
peduncle of the cerebellum (brachium pontis). Still more frequent is the
simple motor hemi-ataxia consequent upon lesion of the medial lemniscus, and
perhaps of longitudinal bundles in the formatio reticularis. This is often
accompanied by a dissociated sensory disturbance, pain and temperature being
affected, while touch remains normal. The muscular sense may also be in-
volved. Only when the lesion is very extensive are there disturbances of hear-
ing (involvement of the lateral lemniscus or corpus trapezoideum ) .
The symptoms produced by involvement of the different cerebral nerves
will be considered in detail in another section.
8. Cerebellum. — The functions of this part of the brain are still under
consideration. Luciani, whose monograph is exhaustive, regards it as " an end
organ, directly or indirectly related to certain peripheral sensory organs and
in direct efferent relationship with certain ganglia of the cerebro-spinal axis,
and indirectly with the motor apparatus in general. It is functionally homo-
geneous, each part exercising the functions of the whole, but having special
relations to the muscles of the corresponding side of the body ^' (Krauss).
Lesions of the lateral lobes affect the corresponding side of the body, while
lesions of the middle lobe (vermis) affect both sides. Partial removal is fol-
lowed by transient muscular weakness; complete removal by extreme inco-
ordination. Its one important function would appear to be the coordination
of the muscular movements.
In monkeys the symptoms differ much at different periods after the opera-
tion. During the first five or six days irritation phenomena predominate.
According to Luciani, there is asthenia, atony of the muscles, and astasia
on the side of the body operated upon. The animal can not stand or walk.
All these symptoms may gradually disappear in the course of a few months.
The experiments of J. S. Risien Eussell do not entirely confirm the obser-
vations of Luciani. In the first place, the occurrence of asthenia is not con-
stant, and as to atony, while the patellar tendon reflexes are sometimes absent,
they are as a rule intact in pure cerebellar lesions. There may be even mus-
cular rigidity instead of atony. Eussell's experiments make it seem likely that
the cerebellar hemisphere of one side exercises constantly an inhibitory effect
upon the activities of the cerebral hemisphere of the opposite side (probably
by way of the brachium conjunctivum). Thus after removal of one cerebellar
hemisphere he found that movements of the arm and leg could be caused by a
faradic stimulation of the contralateral motor area, much milder than that
necessary to stimulate the homolateral motor area. The epileptic seizures fol-
lowing the administration of absinthe were far greater on the side of ablation.
It is not impossible that the explanation of the epileptiform attacks by no
means rare in cerebellar disease is here to be sought.
W. C. Krauss has analyzed the lesions and symptoms in 100 cases of dis-
ease of this part. The morbid conditions were as follows: Sarcoma in 22
cases; tubercle in 22; glioma in 18; abscess in 10; tumor of unspecified origin
in 13 ; cyst in 7 ; and 1 case each of softening, endothelioma, cyst and sarcoma,
cancer, gumma, fibroma, and haemorrhage. The left lobe was affected 32 times,
the right lobe 32 times, and the middle lobe 17 times. Thus tumor constituted
by far the most important affection. There may be no symptoms whatever
if it is in one hemisphere only and does not involve the middle lobe. There
954 DISEASES OF THE NERVOUS SYSTEM.
are instances not only of complete absence of one whole hemisphere from arrest
of growth^ but also of extensive bilateral disease, which throughout life has
yielded no noticeable symptoms. Only when lesions are comparatively sudden
do the symptoms resemble the early experimental states in animals. Other
portions of the brain appear to be able to take on the functions normally
performed by the cerebellum. The most common symptoms in tumor of the
cerebellum are as follows:
Vertigo, which is more constant in this than in affections of any other
region of the brain. Some believe this to be due to involvement of the nervus
vestibularis or its nuclei of termination, by means of which the semicircular
canals are connected with the cerebellum. The symptom was present in 48
of the cases of Krauss' collection, not reported in 43. The vertigo appears
to be entirely independent of the ataxia. Though most frequently associated,
either symptom may be present without the other. The vertigo of cerebellar
disease is often associated with the feeling that objects are revolving about the
body, or that the body itself is moving. Headache was present in 83 cases.
Vomiting occurred in 69 cases, not reported in 23. Optic neuritis was found
in 66 cases, not reported in 23. It is apt to appear early, and is probably
brought about by the obstructive internal hydrocephalus that commonly results
from subtentorial growths through pressure on the aqueductus cerebri.
Of symptoms which are designated as more particularly cerebellar, ataxia,
particularly of the homolateral limbs, is the most important. In cerebellar
ataxia the gait is irregular and staggering, often zigzag, and in attempting to
walk the patient sways to and fro like a drunken man (demarche d'ivresse of
the French writers). As a rule, the patient walks and tends to fall toward the
affected side, but the rule is not certain. The ataxia of cerebellar disease is to
be sharply differentiated from the ataxia of tabes dorsalis, from cortical ataxia,
and probably from the ataxia accompanying diseases of the tegmental portion
of the pons and cerebral peduncle. Cerebellar ataxia is both static and dy-
namic. The opening or closing of the eyes has less influence than in spinal
ataxia. Very important for differential diagnosis is the fact that when the
patient lies in bed movements tolerably well coordinated can be carried out.
The coarse nature of the incoordination distinguishes cerebellar ataxia from
that due to lesion of the cerebral cortex. In the latter the finer movements
(buttoning, etc.) are especially apt to be involved, and there is usually hemi-
paresis or mono-paresis, and often disturbance of muscular sense and of the
stereognostic sense (von Monakow). Cerebellar ataxia may depend upon the
withdrawal of the influence of the cerebellum upon the cerebrum. Babinski
has pointed out that the affected limb, although ataxic, may be held in a given
position more steadily than normal, and also that repeated movements can not
be as quickly performed on the affected as on the normal side.
Paresis, especially of the homolateral trunk muscles, manifest in an in-
ability to perform the movements of bending, erection, and lateral flexion of
the trunk, may be present (Hughlings Jackson). Eisien Russell holds that
the paralysis is " probably directly due to the withdrawal of the cerebellar
influence from the muscles." A peculiar attitude of the head has been de-
scribed, in which the face looks upward and is turned away from the side
occupied by the growth, Deflciency in power of the limbs on the same side
is frequent.
DIFFUSE AND FOCAL DISEASES OF THE BRAIN. 955
Other less constant but suggestive symptoms are neuralgic pains in the
region of the neck and occiput; blocking of the venae Galeni and dilatation
of the lateral ventricles, causing in children hydrocephalus; pressure on the
mid-brain, pons, or medulla oblongata, producing paralysis of the cerebral
nerves (most commonly the sixth cranial), rhythmical contractions of the head
or extremities, nystagmus (particularly when looking toward the side of the
lesion), tremor, anarthria, auditory or visual disturbances. There may be
glycosuria, and bilateral rigidity from pressure on the motor paths. Sudden
death may occur.
The reflexes, though variable, are apt to be increased on the side of the
lesion, and if internal hydrocephalus develops they may be exaggerated on both
sides. When the cerebellar disease involves other structures directly, or indi-
rectly through action at a distance, the reflexes may be abolished.
Symptoms of general mental disturbance may accompany cerebellar dis-
ease, but they are not characteristic. There is often irritability, enfeebled
memory, and toward the end sopor and coma.
II. APHASIA.
Speech disorders give important information as to the position of lesions
of the nervous system, and it is for this reason that they are considered here.
The studies of Boulliaud, Dax, Broca, Bastian, Kussmaul, Lichtheim,
Marie, and others have done much to widen our knowledge of this very diffi-
cult subject. The student is referred to the works of these authors, and
especially to the recent monograph of Moutier.
As in all other voluntary movements speech requires not only a motor but
a sensory apparatus, and we have, as composing the speech mechanism, a
sensory or receptive part as well as a motor or emissive part. These two parts
are associated with the higher centres underlying the intellectual process, and
are controlled by them.
The muscles which are used in the production of articulate speech are many
and widely distributed ; thus, the respiratory muscles, the muscles of the larynx,
the pharynx, the tongue, the lips, and those which move the Jaws, are all
brought into play during speech. These muscles are all active in other less
complicated movements; for instance, respiration, crying, sucking, etc., and
these comparatively simple movements are represented in the gray matter of
the lower motor segment in the pons, medulla, and spinal cord. The asso-
ciation of neurones upon which these movements depend is made during foetal
life, and is in good working order at the time of birth.
As the child's brain grows and takes control of the spinal centres through
the medium of the pyramidal tracts, other more complex movements are de-
veloped and special neurones are set apart for this purpose. There is, then,
a re-representation (Hughlings Jackson) of the finer movements of these mus-
cles in the upper motor segment. They are localized in the central convolu-
tions about the lower part of the Eolandic fissure. All these muscles except
those of the tongue and lips are used bilaterally, and so their movements on
each side of the body are represented on both sides of the brain.
This group of movements, which are in part congenital and in part ac-
quired during the early months of life, is that from which the delicate move-
956 DISEASES OF THE NERVOUS SYSTEM.
meats of articulate speech are developed. The structures upon whicli tliese
movements depend make the primary or elementary speech mechanism.
The cortical centres are in the lower third of the central convolution on
both sides of the brain. They are bilaterally acting centres, and a lesion
limited to either one should not produce marked or permanent defects in
speech. This is true for the right side, but on the left Broca's convolution
and the insula are so closely situated that they are usually injured at the same
time, and motor aphasia results.
The Path &0111 Cortex to Lower Motor Centres. — This is made up of the
motor fibr^ which go to the nuclei of the pons and medulla, and in the
internal eapsole is situated near the knee. As in the cortex, a unilateral
lesion here causes only slight disturbances of speech due to difficult articula-
tion, following weakness of the opposite side of the face and tongue. On the
left gide, if the lesion is so near the cortex as to involve the fibres which
connect Broea's convolution with the primary speech mechanism, subcortical
motor aphasia is produced. Bilateral lesions (usually in the internal capsule,
but at tiines in the c-ortex) cause speechlessness, with jjaralysis of the muscles
of articalation — ^pseudo-bulbar paralysis. To these sjDeech defects Bastian
gives the name Aphemia.
The lower segment of the primary speech mechanism is made up of the
motor nuclei in the medulla, etc., and the peripheral nerves arising from them.
L^ons here, if extensive enough — as, for instance, in progressive bulbar paral-
ysis— may cause speechlessness — anarthria (Bastian) ; but usually they are
more limited, giving various disturbances of articulation.
As the child learns to speak there is developed in the cortex of the brain
an association of centres which takes control of the primary speech mechanism.
The child is constantly heariag objects called by names, and he learns to asso-
ciate certain sounds with the look, feel, taste, etc., of certain things. When
he hears such a sound he gets a more or less clear mental picture of the
object, or, in other words, he has developed certain auditory memories. These
memories of the sounds of words are stored in what is called the auditory
speech centre. This centre, which in the majority of people is the controlling
speech centre, is situated in the first temporal convolution on the left side in
light-handed people, and on the right side in those who are left-handed.
Yarions theories have been advanced to explain the predominance of the left
hemisphere in the speech mechanism, and Weber believes that it is dependent
upon the development of the writing centre in the left motor cortex in associa-
tion with the centre for the right hand. The afferent impressions arising in
the ears reach the tem]>oral lobes, those from each ear going to both sides of
the hrain. From each of these primary auditory centres impulses are sent
to the auditory speech centre in the left hemisphere. The child endeavors,
and by repeated efforts learns, to make the sounds that he hears, and he first
becomes able to repeat words, then to speak voluntarily. To do this, he has
had to learn certain very delicate movements, and so there has been developed
a special motor centre for speech in which these movements are localized.
The Motor Speech Centre. — This has been placed in Broea's convolution,
""' T - ^" :' : \rt of the left third frontal convolution, but the older views as
:: '.'..-z . :ion of aphasia, jsarticularly the motor variety and its associa-
tion with this convolution, have been criticised by Marie, whose views may
DIFFUSE AND FOCAL DISEASES OF THE BRAIN. 957
be studied at leugtli in tlie exbanstive monograph of Moutier. Marie believes
that the pure motor aphasia of writers, anarthria, results from a lesion involv-
ing the left lenticular nucleus and the adjacent zone, which he detines as fol-
lows : In a horizontal section of the brain, the transverse line dra\\Ti from
the anterior angle of the insula to a corresponding point of the lateral ven-
tricle gives the anterior border; a line from the posterior angle of the insula
to a corresponding point of the lateral ventricle gives the posterior limit.
Included in this zone are more than one-half of the thalamus, both limbs of
the internal capsule, the greater part of the caudate nucleus, the lenticular
nucleus, and the island of Eeil with the sulijacent white matter. In a lesion
of this lenticular zone articulate speech alone is affected; internal speech is
preserved, and the patient reads and writes and understands sj)oken speech.
On the other hand, a lesion of the " zone of "Wernicke " causes the sensor)''
aphasia, word deafness and word blindness. According to Marie the zone of
"Wernicke consists of the supramarginal and angular gyii and the feet of the
first two temporal convolutions. When both these regions are affected there
is loss of spontaneous speech, spoken language is not understood, and the
patient can neither read nor write.
Marie's position has been much discussed, and many of the most distin-
guished neurologists have come to the rescue of the old view which accepts
Broca's convolution as the motor speech centre. Dejerine, Mills and Spiller
have published most carefully studied cases which go far to show that the third
left frontal, Broca's convolution, with the insula forms the cortical motor cen-
tre for speech. They agree, however, that lesions of the left lenticular zone
interfere with the movements which make speech possible. These motor sjDeech
areas are connected by commissural fibres through the corpus callosum with
the corresponding areas of the right frontal lobe, and these latter can control
the speech movements when the more direct path in the left p3Tamidal tract
has been interrupted.
The motor speech centres and the corresponding area in the right brain
are connected either directty by special motor fibres with the bulbar nuclei,
or, as is more probable, indirectly, through the medium of the cortical cen-
tres of the primary speech mechanism in the lower part of the Eolandic region
on both sides.
The speech centres are in close connection with the rest of the brain cor-
tex, and in this wa}' they take part in the general mental activities, of which,
indeed, the speech processes form a large part. Some authors have assumed
that the several sensory elements which go to make a concept are brought
together in a sjjecial region of the brain, and here, as it were, united by a
name. This is called " the centre for concepts," or " naming centre " (Broad-
bent), but most vrriters have followed Bastian in considering that the suppo-
sition of such a centre is unnecessary.
The mechanism which has been described is that which is developed in
uneducated jDeople and in children before they have learned to read and write,
and is of primary importance in all speech processes. As the cliild learns to
read he associates certain visual impressions with the speech memories he has
already acquired, and he then adds to his concepts the visual memories of
written or printed s}Tiibols. Tliese memories are stored in the visual speech
centre.
958 . DISEASES OF THE NERVOUS SYSTEM.
The Visual Speech Centre. — This is placed by nearly all authors in the
angular and supramarginal convolutions on the left side, where visual im-
pressions from both occipital lobes are combined in speech memories. Yon
Monakow believes that there is no such special centre, but that visual speech
memories are dependent upon the direct connection of the general visual cen-
tres in both occipital" lobes with the speech sphere. That speech defects result
from injury to the angular and supramarginal convolutions, he admits; but
he thinks these are due to an interruption of fibre tracts which lie beneath
and not to a destruction of a cortical centre. The distinction is, therefore, of
more theoretical than practical importance.
In learning to write, the child develops certain delicate movements of the
arm and hand, and thus acquires another method of externalizing his speech
activities. Whether or not this requires the development of a separate writing
centre, apart from the general Eolandic arm centre, or is brought about by an
evolution of the latter through the medium of Broca's convolution, is a vexed
question. Gordinier has recorded a remarkable case of total agraphia, with
no sensory or motor speech aphasia, in which a tumor occupying the foot of
the second left frontal convolution was found at autopsy. However this may
be, these movements are learned under the influence of visual impressions in
association with the other speech memories, although there is a more direct
path, which is used in copying unknown characters. Just as the movements
of articulate speech are constantly under the control of auditory memories, so
are the movements of writing regulated by visual memories; but in this case
the other speech memories are of great importance.
With the development of the associations which underlie reading and
writing, the speech mechanism may be said to be complete, although its activ-
ities are capable of practically endless extension, as when music or foreign
languages are learned.
It will be seen that the cortical speech centres — the speech sphere of the
French — occupy the part of the brain near the Sylvian fissure, and that they
all receive their blood from the Sylvian artery. Speaking broadly, the pos-
terior part of this region is sensory and the anterior is motor. The sensory
areas are near the optic radiation and the motor are near the general motor
tracts, and so with lesions of the posterior part, hemianopia is apt to be asso-
ciated with the speech disturbance while hemiplegia occurs with disease of
the anterior areas. These associations often help to distinguish a sensory from
a motor aphasia, but each type has special characteristics which must be
studied.
Sensoey Aphasia, due to Lesions of the Posteeior Paet oe the Speech
Aeea, oe to Fibres going to this Eegion.
Auditory Aphasia. — Most people in mentally recalling words do so by
means of their auditory speech inemories — i. e., they think of the sound of
the words, and, in voluntary speech, it is probable that the will acts on the
motor centre indirectly through the auditory centre. This centre is also
necessary for reading in such persons. There are certain persons, however, in
whom the mental processes are carried on by visual memories, and in these
rare " visuals " the visual speech centres take the predominant place in speech
usually occupied by the auditory centres.
DIFFUSE AND FOCAL DISEASES OF THE BRAIN. 959
Complete abolition of all the auditory speech memories by destruction of
the first temporal convolution causes the most extensive disturbances of speech.
Such a person is unable to comprehend speech, either spoken or printed. Vol-
untary speech is much disturbed, and although at first he may talk, his speech
is nothing but a jargon of misplaced words, and he soon becomes speechless.
Writing is also lost, and he can neither repeat words nor write at dictation.
He may be able to copy.
Lesions are often only partial, and the resultant disturbance may be simply
a difficulty in speech due to the loss of nouns or to the transposition of words
(paraphasia), the writing showing the same defect. The patient usually
understands what he hears and reads, and can repeat words and write at
dictation. This is the condition Bastian calls " amnesia verbalis.^^ The con-
dition may be so pronounced that voluntary speech and writing are nearly lost,
even when the auditory memories can still be aroused by new afferent impres-
sions and he is able to understand what is said to him and what he reads. He
can usually repeat and read aloud.
The afferent paths, which reach the auditory speech centre from the two
primary auditory centres, may be destroyed. A lesion to do this must be in
the white matter beneath the first temporal convolution on the left side. Such
a lesion would block all auditory impressions coming to the centre, and the
patient would not be able to understand anything that was said to him, could
not repeat words nor write from dictation. As the cortical centres are not
disturbed, and the auditory speech memories are still present, there is no dis-
turbance of voluntary speech or writing, and the patient can read perfectly.
This is pure word-deafness or subcortical sensory aphasia.
Visual Aphasia. — Destruction of the visual centre in the angular and
supramarginal convolutions causes a loss of the visual speech memories, and the
patient is unable to read printed or written characters. He is unable to write
— i, e., there is agraphia — and he can not copy. His understanding of spoken
words is good, and voluntary speech is normal or only slightly paraphasic.
A subcortical lesion involving the afferent fibres going to the visual speech
centre causes pure word-blindness (subcortical alexia) — i. e., there is inability
to understand written or printed words. Voluntary speech and writing are
good. The patient can not read his own writing except by aid of muscle-
sense impression, in retracing the letters, either voluntary or passively. Asso-
ciated with this is always hemianopia.
Word-deafness and word-blindness are often combined, and at times it
is not only the tracts that connect the primary auditory and visual centres
with the speech spheres, but also those which associate them with the other
sensory centres in the formation of concepts, that are diseased. In this case
the patient has lost not only his auditory and visual speech memories, but also
all of his memories which have to do with hearing and sight, and he has mind-
deafness and mind-blindness — i. e., he is unable to recognize objects when he
hears or when he sees them. Further than this, there may be a dissociation
of all the sensory centres from each other or from the higher psychical centre,
which is practically the same thing, in which case the patient is entirely unable
to recognize objects and to use them properly — i. e., he has apraxia. Apraxia
may occur alone, but is usually associated with forms of aphasia. A sensory
and a motor type have been described.
960 DISEASES OF THE NERVOUS SYSTEM.
Motor Aphasia. — Lesions of the motor sijeecli zone, jiossibly in rare cases
of Broca's convolution alone, more conmionly of a wider area, cause loss of
the power of speech. The patient may be absolutely dumb, or he. may have
retained one or two words or phrases, which is believed to be due to the activ-
ity of the corresponding region of the right brain. He will make no effort
to repeat words. His mind is comparatively clear, and he understands what
is said to him and is able to read, although there is usually some difficulty in
this due to the lack of motor speech memories. He will not be able to indi-
cate that he has a mental picture of words. This is tested by asking him to
squeeze the observer's hand or to make expiratory efforts as many times as
there are syllables in a well-known name.
Voluntary writing is usually lost in cortical motor aphasia, and many
authors believe that writing movements are controlled from this centre.
Others, who believe that there is a special writing centre, contend that a
lesion strictly limited to the motor speech centre would not cause agraphia,
and cite cases which seem to support their view. If there is much disturb-
ance of internal speech, writing will be impaired.
Subcortical motor aphasia is described as due to the destruction of the
fibres which join Broca's convolution to the primary speech mechanism.
Lesions which have produced this type of aphasia have been in the white mat-
ter of the left hemisjjhere near Broca's convolution. These would be within
Marie's speech zone. There is complete loss of the power of speech without
any disturbance of internal speech. The patient's mental processes are not
disturbed, and he can write perfectly if the hand is not paralyzed.
Cases of aphasia are rarely simple, and it is often impossible to classify
them accurately. The problems involved are, in reality, exceedingly com-
plicated, and the student must not for a moment suppose that cases are as
straightforward as the various diagrams at first sight would appear to indi-
cate. A majority of them are very complex, but with patience the diagnosis
of the different varieties can often be worked out. The following tests should
be applied in each case of aphasia, after the presence or absence of paralysis
has been determined and whether the patient is right-handed or left-handed:
(1) The power of recognizing the nature, uses, and relations of objects — ■
i. e., whether apraxia is present or not; (2) the power to recall the name of
familiar objects seen, smelted, or tasted, or of a sound when heard, or of an
object touched; (3) the power to understand spoken words; (4) the capa-
bility of understanding printed or written language ; ( 5 ) the power of appre-
ciating and understanding musical tunes; (6) the power of voluntary speech
— in this it is to be noted particularly whether he misplaces words or not;
(7) the power of reading aloud and of understanding what he reads; (8)
the power to write voluntarily and of reading what he has written; (9) the
power to copy; (10) the power to write at dictation; and (11) the power
of repeating words. Stone and Douglas have recently described (Brain, 1902)
a form of familial disease under the name of hereditary aphasia.
The medico-legal aspects of aphasia are of great importance. No general
principle can be laid down, but each case must be considered on its merits.
Langdon, in reviewing the whole question, concludes : " Sanity established,
any legal document should be recognized when it can be proved that the
person making it can understand fully its nature by any receptive channel
DIFFUSE AND FOCAL DISEASES OF THE BRAIN. 961
(viz., hearing, vision, or muscular sense), and can, in addition, express assent
or dissent with certainty to proper witnesses, whether this expression be by-
spoken speech, written speech, or pantomime."
Prognosis and Treatment of Aphasia. — In young persons the outlook is
good, and the power of speech is gradually restored apparently by the educa-
tion of the centres on the opposite side of the brain. In adults the condition
is less hopeful, particularly in the cases of complete motor aphasia with right
hemiplegia. The patient may remain speechless, though capable of under-
standing everything, and attempts at re-education may be futile. Partial
recovery may occur, and the patient may be able to talk, but misplaces words.
In sensory aphasia the condition may be only transient, and the different forms
rarely persist alone without impairment of the powers of expression.
The education of an aphasic person requires the greatest care and patience,
particularly if, as so often happens, he is emotional and irritable. It is best
to begin by the use of detached letters, and advance, not too rapidly, to
words of only one syllable. Children often make rapid progress, but in adults
failure is only too frequent, even after the most painstaking efforts. In the
cases of right hemiplegia with aphasia the patient may be taught to write
with the left hand. Mills has lately called particular attention to the benefit
of this treatment.
III. AFFECTIONS OF THE BLOOD-VESSELS.
1. Cerebral Circulation.
There is much that is still indefinite in the physiology of the circulation
of the brain, but that which is known is of the greatest practical moment to
the physicians. To the work of Leonard Hill (see his summary in Allbutt's
System) I am much indebted for many of the facts in the following brief
sketch :
The brain receives blood from the internal carotid arteries, the vertebrals,
and, to some extent, from the spinal arteries. These anastomose soon after
entering the skull to form the circle of Willis. The extent of this intercom-
munication is subject to considerable variation, which may be of extreme
importance in pathological conditions. Collected by the veins, the blood is
emptied into large venous sinuses, which are, to a great extent, protected from
pressure changes by the skull and dura mater.
The cerebro-spinal fluid is collected in the meningeal spaces and fills the
interstices between the convolutions, etc. Under normal conditions there is
but a small quantity of this fiuid within the skull, which is entirely filled
with brain, blood, and the cerebro-spinal fiuid. Practically a closed box, with
contents uninfiuenced by atmospheric pressure, the quantity of blood within
the skull under normal circumstances is almost constant, for the brain sub-
stance itself can not be compressed, so that the only increase or decrease
is that which compensates for the small quantity of cerebro-spinal fiuid that
can pass between the cranial and spinal cavities.
Although the quantity of blood does not change materially, its rapidity
of flow may, and does, show marked variations, and thus the relation between
arterial and venous blood is subject to change. The circulation within the
skull not only differs from the circulation in other parts in its freedom from
63
962 DISEASES OF THE NERVOUS SYSTEM.
the effects of atmospheric pressure, but apparently it is not under local vaso-
motor control and is in an organ that can only expand slightly. Although nerve
fibres have been demonstrated in the walls of the small arteries of the brain,
it has not been proved that they cause dilatation or contraction under influ-
ences from the vaso-motor centres ; indeed, there is little experimental evidence
that speaks for, and much that speaks against, this view.
Under ordinary circumstances, the circulation of the brain follows passively
the general bodily conditions. When anything increases the force with which
the blood enters the skull — i. e., when blood-pressure is raised, either by in-
crease in the heart's action or by general vaso-motor effects — more blood passes
through the brain in a given time, and it is, as it were, flooded with blood.
This active hyperaemia must occur under many circumstances, but it is doubt-
ful whether it causes any symptoms; in fact, it is difficult to see how it, in
itself, can do anything but good.
Although without direct vaso-motor control, the circulation of the brain
is regulated by the action of the vaso-motor centre on the splanchnic areas
and skin. This centre itself shares with the respiratory and cardiac centres
the same circulatory conditions as prevail throughout the brain.
Consciousness depends upon a due blood supplj^ to the brain, particularly
to the cortex, and life itself depends upon the circulation in the medullary
centres. When the blood circulating about these centres is poor in oxygen —
i. e., when there is a lack of arterial blood — the arterioles within the splanchnic
and skin areas contract under vaso-motor influences, the blood-pressure is
raised, and the blood enters the brain with unusual force and supplies the
capillaries with arterial blood. The extent to which this regulating mechan-
ism can counteract an obstruction to the circulation through these centres
has been well shown experimentally by Harvey Gushing. When the general
intracranial pressure was raised to arterial, blood-pressure, instead of the circu-
lation being blocked and the animal dying from ansemia of the brain, as had
been stated by a number of authors, he showed that the vaso-motor centres
responded with a sufficient rise of blood-pressure to overcome the impediment,
and so restore the circulation. With every repeated increase of intracranial
pressure, there was an answering rise of blood-pressure, until, at the end of
the experiment, the brain was acting under an intracranial pressure much
above the arterial pressure of the animal at the beginning of the experiment,
and this pressure had been correspondingly raised to a startling extent. The
interesting clinical deductions which Gushing draws from this experiment
will be referred to under cerebral hsemorrhage.
When this regulating mechanism is disturbed, serious results may follow.
The ordinary fainting fit is an example : Under the influence of emotion the
vaso-motor centre is inhibited, and, in consequence, the abdominal blood-
vessels become dilated, blood-pressure falls, and the heart is no longer able
to drive the blood back to itself against the force of gravity ; the blood accumu-
lates in the abdominal veins, the heart empties, cerebral circulation fails, and
unconsciousness occurs. A similar condition may follow the sudden removal
of something that has caused pressure on the abdominal vessels for a consider-
able time, as the withdrawal of the ascitic fluid. In this case the vaso-motor-
control influences have not been called on for some time, and the centre itself
has taken part in the general weakened condition of the individual, so that
DIFFUSE AND FOCAL DISEASES OF THE BRAIN. 963
when a sudden demand is made upon it to compensate for the accustomed
external support to the blood-vessels, it is entirely unable to respond, and the
blood collects in the splanchnic vessels, the patient becomes unconscious and
may die, having bled to death into his own veins.
While under ordinary circumstances the vaso-motor mechanism and the
tonicity of the muscles of the abdominal walls compensate perfectly for the
change from the horizontal to the upright position — i. o., for the effect of
gravity upon the column of venous blood from the heart to the feet, in
asthenic states, as after severe illness, the compensation may be very imper-
fect. When such is the case, if the patient stands, or, at times, even if he
sits up in bed, his heart beats more rapidly, he becomes giddy and may faint.
The change in the pulse-rate, with a change in position, is a fair indication
of the vaso-motor control, for the heart itself endeavors to make up for this
incompetence.
Chloroform and, to a less extent, ether tend to induce vaso-motor paraly-
sis, and this is the reason why position is such an important factor in the
safety of patients during anaesthesia. The splanchnic circulation, under these
circumstances, may, to a certain extent, be supported by bandaging the legs
and abdomen and elevating the foot of the bed. Crile's pneumatic operating
suit, in which the patient is encased below the chest in an inflatable suit, by
means of which pressure on the peripheral and abdominal vessels may be
varied, is an attempt to establish an artificial vaso-constrictor system under
the control of the operator, which can compensate for the paralyzing effects
of the anaesthetic, and obviate the necessity of considering position.
The heart itself may become weak from various causes and so be unable
to keep the brain properly supplied with arterial blood. The extreme example
of this is paralysis of the heart muscles from failure of the coronary circula-
tion, which is immediately followed by unconsciousness and death. In Stokes-
Adams disease the cerebral symptoms, attacks of unconsciousness, convulsions,
and apoplectiform seizures are due to cerebral ansemia, caused by the tempo-
rary cessation of the ventricular systole. When the chest is forcibly com-
pressed the heart may be unable to fill itself with blood, and so unconscious-
ness, or even death, may follow from failure of the cerebral circulation.
Kespiration is an essential part of circulation; this is true not only in
the primary sense, that it is through this function that venous is changed into
arterial blood, but also in a more truly mechanical sense. With every inspira-
tion the blood is sucked into the heart from the veins, and the descent of the
diaphragm, by increasing the pressure on the abdominal veins, tends to force
the blood into the heart. During expiration the entrance of the blood into
the heart is impeded by the increase in the intra-thoracic pressure. Eespira-
tion has direct, but slight, influence upon the blood-pressure within the
arteries.
The circulation within the skull is very intimately related to respiration.
The blood from the brain sinuses passes through the jugular veins directly
into the superior vena cava and the columns of blood appear to be uninter-
rupted by competent valves, so that every change of pressure in the cava is
transmitted directly to the sinuses and veins of the brain. Intracranial
pressure has been shown to be equal to venous blood-pressure within the
sinuses and to follow every change in this. The brain dilates with each pulse-
964 DISEASES OF THE NERVOUS SYSTEM.
beat, but relatively much more with each expiration. In expiration intra-
thoracic pressure is increased, and this causes an increase in the pressure
within the cava, the jugular, and the brain sinuses. The blood is, as it were,
dammed back, venous congestion occurs, intracranial pressure rises, and the
brain receives less arterial blood, and the symptoms of cerebral anaemia may
follow. Under ordinary conditions these effects are not so pronounced or
protracted as to cause marked symptoms, but at times they may be, as when
a crying child holds his breath until he becomes unconscious. Here the diffi-
culty which the heart has in filling itself with blood under increased thoracic
pressure is also a factor. When the superior vena cava is alone obstructed, as
by pressure from a tumor, there may be not the slightest disturbance of the
functions. This depends upon the freedom of the cranio-vertebral venous
anastomosis, and other paths which allow the blood to reach the heart through
the inferior vena cava. Strong respiratory efforts against an obstruction may
change intrathoracic pressure very greatly. In forced expiration with the
glottis closed, the normal negative pressure becomes markedly positive and may
far exceed the normal pressure in the intrathoracic veins, while, if the glottis
be closed and a strong inspiratory effort be made, the pressure may fall far
below atmospheric pressure. Intracranial haemorrhages not infrequently take
place during a strong effort with the breath held as when straining at stool,
or when lifting a heavy weight, or during a severe coughing spell, all condi-
tions in which, among other things, the flow of the venous blood from the
brain to the heart is impeded, and in consequence of which intracranial circu-
latory conditions are altered in the direction of a rise of venous and capillary
pressure. The importance of preventing, as far as possible, any obstruction
to respiration during the course of apoplexy, will be referred to in a subse-
quent paragraph.
The venous outlets from the skull are so large and the anastomoses are so
free that they must all be obstructed to cause any marked anemia of the brain,
and for this reason thrombosis or ligature of one of the sinuses is not neces-
sarily followed by any symptoms. If all the veins in the neck are compressed
as by a tight band or strong flexion of the neck, the circulation may be impeded
to a considerable extent, and this is of definite importance under pathological
conditions.
Any one of the arteries may be tied before entering the skull, with but
little danger, owing to the freedom of the anastomosis in the circle of Willis,
but, as this is subject to variation, the closure should be made slowly. With
this precaution, both carotids may be tied if an interval be allowed between
the operations.
Obliteration of an artery beyond the circle of Willis is always followed by
a disturbance of function of the part of the brain supplied by that artery,
and is considered under Embolism and Thrombosis.
2. Hyperemia and Anemia.
Less and less stress is now laid on active hypergemia as a cause of symptoms.
As Leube suggests, the symptoms usually referred to active hypergemia in the
infectious diseases, or in association with hypertrophy of the heart accom-
panying disease of the kidney, are due to the action of toxic agents rather than
DIFFUSE AND FOCAL DISEASES OF THE BRAIN. 965
to changes in the circulation. On the other hand, venous stasis and anaemia
of the brain must be a very potent cause of head symptoms. The uncertainty
which exists is largely due to the fact that the condition of the blood-vessels
as seen within the skull after death may bear no relation to that which held
sway during life.
The anatomical condition of the brain in anaemia is very striking. The
membranes are pale, only the large veins are full, the small vessels over the
gyri are empty, and an unusual amount of cerebro-spinal fluid is present. On
section both the gray and white matter look extremely pale and the cut surface
is moist. Very few puncta vasculosa are seen.
The effects of sudden anaemia of the brain are well illustrated By the ordi-
nary fainting fit, and have been described above.
Symptoms. — When the symptoms are the result of haemorrhage, there are
drowsiness, giddiness, inability to. stand ; flashes of light, dark spots before the
eyes, and noises in the ears; the respiration becomes hurried; the skin is cool
and covered with sweat; the pupils are dilated, there may be vomiting, head-
ache, or delirium, and gradually, if the bleeding continues, consciousness is
lost and death may occur with convulsions. In the more chronic forms of
brain anaemia, such as result from the gradual impoverishment of the blood,
as in protracted illness or in starvation, the condition known as irritable weak-
ness results. Mental effort is difficult, the slightest irritation is followed by
undue excitement, the patient complains of giddiness and noises in the ears,
or there may be hallucinations or delirium. These symptoms are met with
in an extreme grade as a result of prolonged starvation, and a very similar
condition is seen in certain cases of arterio-sclerosis where the brain is poorly
nourished.
An interesting set of symptoms, to which the term hydrencepJialoid was
applied by Marshall Hall, occurs in the debility produced by prolonged diar-
rhoea in children. The child is in a semi-comatose condition with the eyes
open, the pupils contracted, and the fontanelle depressed. In the earlier
period there may be convulsions. The coma may gradually deepen, the pupils
become dilated, and there may be strabismus and even retraction of the head,
symptoms which closely simulate those of basilar meningitis.
3. CEdema of the Beain.
In the pathology of brain lesions oedema formerly played a role almost
equal in importance to congestion. It occurs under the following conditions :
In general atrophy of the convolutions, in which case the oedema is represented
by an increase in the cerebro-spinal fluid and in that of the meshes of the pia.
In extreme venous dilatation from obstruction, as in mitral stenosis or in
tumors, there may be a condition of congestive oedema, in which, in addition
to great filling of the blood-vessels, the substance of the brain itself is un-
usually moist. The most acute oedema is a local process found around tumors
and abscesses. The symptoms of compression following concussion or con-
tusion, as shown by Cannon, are frequently attributable to cerebral oedema due
to change in osmotic pressure. An intense infiltration, local or general, may
occur in Bright's disease, and to it, as Traube suggested, certain of the uremic
symptoms may be due.
966 DISEASES OF THE NERVOUS SYSTEM.
The anatomical changes are not uiilike those of anaemia. When the oedema
follows progressive atrophy, the fluid is chiefly within and beneath the mem-
branes. The brain substance is anaemic and moist, and has a wet, glistening
appearance, which is very characteristic. In some instances the oedema is
more intense and local, and the brain substance may look infiltrated with fluid.
The amount of fluid in the ventricles is usually increased.
The symptoms are in great part those of lessened blood-flow, and are not
well defined. As just stated, some of the cerebral features of uraemia may
depend upon it. Cases have been reported by Ea^Tuond, Tenneson, and Der-
cum, in which unilateral convulsions or paralysis have occurred in connection
with chronic Bright's disease, and in which the condition appeared to be asso-
ciated with oedema of the brain. The older writers laid great stress upon an
apoplexia serosa, which may really have been a general oedema of the brain.
Inasmuch as the instances in which oedema of the brain occurs are often those
in which there is also intoxication, or anaemia, or both, it is probably impossible
to say at the bedside definitely which of these possible factors is responsible
for the symptoms in a given case.
4. CeEEBEAL H-2EM0KKHAGE.
The bleeding may come from branches of either of the two great groups
of cerebral vessels — the hasal, comprising the circle of Willis and the central
arteries passing from it and from the first portion of the cerebral arteries, or
the cortical group, the anterior, middle, and the posterior cerebral vessels. In
a majority of the cases the haemorrhage is from the central branches, more par-
ticularly from those which are given oS by the middle cerebral arteries in the
anterior perforated spaces, and which supply the corpora striata and internal
capsules. One of the largest of these branches which passes to the third divi-
sion of the lenticular nucleus and to the anterior part of the internal capsule,
the lenticulo-striate artery of Buret, is so frequently involved in haemorrhage
that it has been called by Charcot the artery of cerebral hcemorrhage. Haemor-
rhages from this and from the lenticulo-thalamic artery include more than
60 per cent of all cerebral haemorrhages. The bleeding may be into the sub-
stance of the brain, to wliich alone the term cerebral apoplexy is applied, or
into the membranes, in which case it is termed meningeal haemorrhage; both,
however, are usually included under the terms intracranial or cerebral haem-
orrhage.
Etiology. — The conditions which produce lesions of the blood-vessels play
a very important part ; thus the natural tendency to degeneration of the vessels
in advanced life makes apoplexy much more common after the fiftieth year.
It may, however, occur in children under ten. On account of the greater
liability to arterial disease (associated probably with muscular exertion and
the abuse of alcohol), men are more subject to cerebral haemorrhage than
women. Heredity was formerly thought to be an important factor in this
affection, and the apoplectic hahitus or build is still referred to. By this is
meant a stout plethoric body of medium size, with a short neck. Heredity
influences cerebral haemorrhage entirely through the arteries, and there are
families in which these degenerate early, usually in association with renal
changes. The secondary hj-pertrophy of the heart brings with it serious dan-
DIFFUSE AND FOCAL DISEASES OF THE BRAIN. -967
gers, which have already been discussed in the section upon arteries. The
special factors in inducing arterio-sclerosis — the abuse of alcohol, immoderate
eating, syphilis, and prolonged muscular exertion — are found to be important
antecedents in a large number of cases of cerebral hasmorrhage. Chronic lead
poisoning and gout also may here be mentioned.
The endocarditis of rheumatism and other fevers may indirectly lead to
apoplexy by causing embolism and aneurism of the vessels of the brain. Cere-
bral heemorrhage occurs occasionally in the specific fevers and in profound
alterations of the blood, as in leukaemia and pernicious anaemia. The actual
exciting cause of the haemorrhage is not evident in the majority of cases. The
attack may be sudden and without any preliminary symptoms. In other in-
stances violent exertion, particularly straining efforts, or the excited action of
the heart in emotion may cause a rupture.
Morbid Anatomy. — The lesions causing apoplexy are almost invariably
in the cerebral arteries, in which the following changes may lead directly
to it:
(a) The production of miliary aneurisms, rupture of which is the most
common cause of cerebral haemorrhage. The origin of the miliary aneurisms
is disputed. Charcot thought they resulted from changes in the adventitia
(periarteritis). Others, with Eichler, Ziegler, and Birch- Hirschf eld, find the
primary change in the intima. The weight of opinion at present, however, is
on the side of the view that the media is first degenerated (Eoth, Loewenthal).
They occur most frequently on the central arteries, but also on the smaller
branches of the cortical vessels. On section of the brain substance they may
be seen as localized, small dark bodies, about the size of a pin's head. Some-
times they are seen in numbers upon the arteries when carefully withdrawn
from the anterior perforated spaces. According to Charcot and Bouchard, who
have described them, they are most frequent in the central ganglia. In apo-
plexy after the fortieth year if sought for they are rarely missed. The actual
miliary aneurism, which by its rupture has occasioned the hasmorrhage, may
be difficult to find, but if one pours water carefully on the area of haemorrhage,
or, better still, submerges the apoplectic mass for a time, it will usually be
found possible to do so, and even to find the hole in its wall.
(&) Aneurism of the branches of the circle of Willis. These are by no
means uncommon, and will be considered subsequently.
(c) Endarteritis and periarteritis in the cerebral vessels most commonly
lead to apoplexy by the production of aneurisms, either miliary or coarse.
There are instances in which the most careful search fails to reveal anything
but diffuse degeneration of the cerebral vessels, particularly of the smaller
branches; so that we must conclude that spontaneous rupture may occur
without the previous formation of aneurism.
(d) Increased permeability of the walls of the vessels may account for
haemorrhages by diapedesis without actual rupture. Such haemorrhages are
not uncommon in cases of contracted kidney, grave anaemia, and various
infections and intoxications.
(e) In persons over sixty the hemiplegia may depend upon small areas of
softening in the gray matter — the lacunce of Marie — areas varying in size from
a pin's head to a pea or a small bean, grayish-red in tint. The lenticular
nucleus is particularly apt to be involved. The blood-vessels are always dis-
968. DISEASES OF THE NERVOUS SYSTEM.
eased. Anatomically this is believed to be quite as important as the miliary
aneurisms.
The haemorrhage may be meningeal, cerebral, or intraventricular.
Meningeal licemorrhage may be outside the dura, between this membrane
and the bone, or between the dura and arachnoid, or between the arachnoid
and the pia mater. The following are the chief causes of this form of haemor-
rhage : Fracture of the skull, in which case the blood usually comes from the
lacerated meningeal vessels, sometimes from the torn sinuses. In these cases
the blood is usually outside the dura or between it and the arachnoid. The
next most frequent cause is rupture of aneurisms on the larger cerebral ves-
sels. The blood is usually subarachnoid. An intracerebral haemorrhage may
burst into the meninges. A special form of meningeal hsemorrhage is found
in the new-born, associated with injury during birth. And lastly, meningeal
haemorrhage may occur in the constitutional diseases and fevers. The blood
may be in a large quantity at the base ; in cases of ruptured aneurism, particu-
larly, it may extend into the cord or upon the cortex. Owing to the greater
frequency of the aneurisms in the middle cerebral vessels, the Sylvian fissures
are often distended with blood.
Intracerebral hcemorrhage is most frequent in the neighborhood of the cor-
pus striatum, particularly toward the outer section of the lenticular nucleus.
The hgemorrhage may be small and limited to the lenticular body, the thala-
mus, and the internal capsule, or it may extend to the insula. Haemorrhages,
confined to the white matter — the centrum semiovale — are rare. Localized
bleeding may occur in the crura or in the pons. Haemorrhage into the cere-
bellum is not uncommon, and usually comes from the superior cerebellar
artery. The extravasation may be limited to the substance or may rupture
into .the fourth ventricle. Twice I have known sudden death in girls under
twenty-five to be due to cerebellar haemorrhage.
Ventricular Hcemorrhage. — This occasionally but rarely is primary, coming
from the vessels of the plexuses or of the walls. More often it is secondary,
following haemorrhage into the cerebral substance. It is not infrequent in
early life and may occur during birth. Of 94 cases collected by Edward
.Sanders, 7 occurred during the first year, and 14 under the twentieth year.
In the cases which I have seen in adults it has almost always been caused by
rupture of a vessel in the neighborhood of the caudate nucleus. Tlie blood
may be found in one ventricle only, but more commonly it is in both lateral
ventricles, and may pass into the third ventricle and through the aqueduct of
Sylvius into the fourth ventricle, forming a complete mould in blood of the
ventricular system. In these cases the clinical picture may be that of "^ apo-
plexie foudroyante."
Subsequent Changes. — The blood gradually changes in color, and ulti-
mately the haemoglobin is converted into the reddish-brown hamatoidin. In-
flammation occurs about the apoplectic area, limiting and confining it, and
ultimately a definite wall may be produced, inclosing a cyst with fluid contents.
In other instances a cyst is not formed, but the connective tissue proliferates-
and leaves a pigmented scar. In meningeal haemorrhage the effused blood
may be gradually absorbed and leave only a staining of the membranes. In
other cases, particularly in infants, when the effusion is cortical and abundant,
there may be localized wasting of the convolutions and the production of a cyst
DIFFUSE AND FOCAL DISEASES OF THE BRAIN. 969
in the meninges. Possibly certain of the cases of porencephaly are caused in
this way.
Secondary degeneration follows, varying in character according to the loca-
tion of the haemorrhage and the actual damage done by it to nerve cells or
their medullated axones. Thus, in persons dying some years after a cerebral
apoplexy which has produced hemiplegia (lesion of the motor area in the
cortex or of the pyramidal tract leading from it), the degeneration may be
traced through the cerebral peduncle, the ventral part of the pons, the pyra-
mids of the medulla, the fibres of the direct pyramidal tract of the cord of the
same side, and the fibres of the crossed pyramidal tract on the opposite side.
After haemorrhages in the middle and inferior frontal gyri there follows degen-
eration of the frontal cerebro-cortico-pontal path, going through the anterior
limb of the internal capsule and the medial portion of the basis pedunculi to
.the nuclei pontis; also degeneration of the fibres connecting the nucleus me-
dialis thalami, and the anterior part of the nucleus lateralis thalami with the
cortex (Flechsig, v. Monakow).
When the temporal gyri or their white matter is destroyed by a haemor-
rhage the lateral segment of the basis pedunculi degenerates (Dejerine) . Cere-
bellar hemorrhage, especially if it injure the nucleus dentatus, may lead to
degeneration of the brachium conjunctivum.
The]-e may be slow degeneration in the lemniscus medialis, extending as
far as the nuclei on the opposite side of the medulla oblongata, after haemor-
rhages in the central gyri, hypothalamic region, or dorsal part of the pons.
Hemorrhages destroying the occipital cortex, or subcortical haemorrhages in-
juring the optic radiations, occasion slow degeneration (cellulipetal) of the
radiations from the lateral geniculate body, and after a time cause marked
atrophy or even disappearance of its ganglion cells.
Symptoms. — These may be divided into primary, or those connected with
the onset, and secondary, or those which develop later, after the early mani-
festations have passed away.
Peimary Symptoms. — Premonitory indications are rare. As a rule, the
patient is seized while in full health or about the performance of some every-
day action, occasionally an action requiring strain or extra exertion. Now and
then instances are found in which there are sensations of numbness or tingling
or pains in the limbs, or even choreiform movements in the muscles of the
opposite side, the so-called prehemiplegic chorea. In other cases temporary
disturbances of vision and of associated movements of the eye-muscles have
been noted, but none of the prodromata of apoplexy (the so-called "warn-
ings") are characteristic. The onset of the apoplexy, as the symptoms of
cerebral haemorrhage are usually called, varies greatly. There may be sudden
loss of consciousness and complete relaxation of the extremities. In such in-
stances the name apoplectic stroke is particularly appropriate. In other cases
the onset is more gradual and the loss of consciousness may not occur for a
few minutes after the patient has fallen, or after the paralysis of the limbs
is manifest. In the typical apoplectic attack the condition is as follows:
There is deep unconsciousness; the patient can not be roused. The face is
injected, sometimes cyanotic, or of an ashen-gray hue. The pupils vary ; usu-
ally they are dilated, sometimes unequal, and always, in deep coma, inactive.
If the hemorrhage be so located that it can irritate the nucleus of the third
970 DISEASES OF THE NERVOUS SYSTEM.
nerve the pupils are contracted (hemorrhages into the pons or ventricles).
The respirations are slow, noisy, and accompanied with stertor. Sometimes
the Cheyne-Stokes rhythm may be present. The chest movements on the
paralyzed side may be restricted, in rare instances on the opposite side. The
cheeks are often blown out during expiration, with spluttering of the lips.
The pulse is usually full, slow, and of increased tension. The temperature may
be normal, but is often found subnormal, and, as in a case reported by Bastian,
may sink below 95°. In cases of basal hsemorrhage the temperature, on the
other hand, may be high. The urine and faeces are usually passed involun-
tarily. Convulsions are not common. It may be difficult to decide whether
the condition is apoplexy associated with hemiplegia or sudden coma from
other causes. An indication of hemiplegia may be discovered in the difference
in the tonus of the muscles on the two sides. If the arm or the leg is lifted,
it drops " dead " on the affected side, while on the other it falls more slowly.
Heilbroener has lately pointed out that the lack of muscular tone of the
paralyzed limb may be determined by inspection. In this condition the muscle
mass of the thigh acts like a semi-fluid sac and takes the shape determined by
gravity. In a patient lying or sitting on a firm support, the thigh of the
paralyzed limb is broadened or flattened, while that on the normal side has a
more rounded contour. Eigidity also may be present. In watching the move-
ments of the facial muscles in the stertorous respiration it will be seen that on
the paralyzed side the relaxation permits the cheek to be blown out in a more
marked manner. The head and eyes may be turned strongly to one side —
conjugate deviation. In such an event the turning is toward the side of the
hgemorrhage.
In other cases, in which the onset is not so abrupt, the patient may not
lose consciousness, but in the course of a few hours there is loss of power,
unconsciousness gradually develops, and deepens into profound coma. This
is sometimes termed ingravescent apoplexy. The attack may occur during
sleep. The patient may be found unconscious, or wakes to find that the power
is lost on one side. Small haemorrhages in the territory of the central arteries
may cause hemiplegia without loss of consciousness. In old persons the hemi-
plegia may be slight and follow a transient loss of consciousness, and is usu-
ally most marked in the leg, which is dragged. It may be quite slight and
difficult to make out. It is associated with other senile changes. This is the
form very often due to the presence of lacunar softening.
Usually within forty-eight hours after the onset of an attack, sometimes
within from two to six hours, there is febrile reaction, and more or less con-
stitutional disturbance associated with inflammatory changes about the hem-
orrhage and absorption of the blood. The period of inflammatory reaction
may continue for from one week to two months. The patient may die in this
reaction, or, if consciousness has been regained, there may be delirium or
recurrence of the coma. At this period the so-called early rigidity may develop
in the paralyzed limbs. The so-called trophic changes may occur, such as
sloughing or the formation of vesicles. The most serious of these is the
sloughing eschar of the lower part of the back, or on the paralyzed side, which
may appear within forty-eight hours of the onset and is usually of grave sig-
nificance. The congestion at the bases of the lungs so common in apoplexy is
regarded by some as a trophic change.
DIFFUSE AND FOCAL DISEASES OF THE BRAIN. " 971
Conjugate Deviation. — In a right hemiplegia the eyes and head may be
turned to the left side; that is to say, the eyes look toward the cerebral lesion.
This is almost the rule in the conjugate deviation of the head and eyes which
occurs early in hemiplegia. When, however, convulsions or spasm develop or
the state of so-called early rigidity in hemiplegia, the conjugate deviation
of the head and eyes may be in the opposite direction ; that is to say, the eyes
look away from the lesion and the head is rotated toward the convulsed side.
This symptom may be associated with cortical lesions, particularly, according
to some authors, when in the neighborhood of the supramarginal and angular
gyri. It may also occur in a lesion of the internal capsule or in the pons, but
in the latter situation the conjugate deviation is the reverse of that which
occurs in other cases, as the patient looks away from the lesion, and in spasm
or convulsion looks toward the lesion.
Hemiplegia. — In cases in which consciousness is restored and the patient
improves, a unilateral paralysis may persist due to the destruction of the
motor area or the pyramidal tract in any part of its course. Hemiplegia is
complete when it involves face, arm, and leg, or partial when it involves only
one or other of these parts. This may be the result of a lesion (a) of the
motor cortex; (&) of the pyramidal fibres in the corona radiata and in
the internal capsule; (c) of a lesion in the cerebral peduncle; or (d) in the
pons Varolii. The situation of the lesions and their effects are given in Fig. 9.
Hgemorrhage is perhaps the most common cause, but tumors and spots of
softening may also induce it. The special details of the hemiplegia may here
be considered. The face (except in lesions in the lower part of the pons) is
involved on the same side as the arm and leg. This results from the fact that
the facial muscles stand in precisely the same relation to the cortical centres
as those of the arm and leg, the fibres of the upper motor segment of the facial
nerve itora the cortex decussating just as do those of the nerves of the limbs.
The signs of the facial paralysis are usually well marked. There may be a
slight difficulty in elevating the eyebrows or in closing the eye on the paralyzed
side, or in rare cases the facial paralysis is complete, but the movements may
be present with emotion, as laughing or crying. The facial paralysis is par-
tial, involving only the lower portion of the nerve, so that the orbicularis oculi
and the frontalis muscles are much less involved than the lower branch. The
hypoglossal nerve also is involved. In consequence, the patient can not put
out the tongue straight, but it deviates toward the paralyzed side, inasmuch
as the genio-hyo-glossus of the sound side is unopposed. With right hemiplegia
there Taa.y be aphasia. Even without marked aphasia difficulty in speaking
and slowness are common.
The arm is, as a rule, more completely paralyzed than the leg* The loss
of power may be absolute or partial. In severe cases it is at first complete.
In others, when the paralysis in the face and arm is complete that of the leg
is only partial. The face and arm may alone be paralyzed, while the leg
escapes. Less commonly the leg is more affected than the arm, and the face
may be only slightly involved.
Certain muscles escape in hemiplegia, particularly those associated in
symmetrical movements, as those of the thorax and abdomen, a fact which
Broadbent explains by supposing that as the spinal nuclei controlling these
movements on both sides constantly act together, they may, by means of this
972
DISEASES OF THE NERVOUS SYSTEAI.
intimate connection, be stimulated by impulses coming from only one side
of the brain. Hughlings Jackson pointed out that in quiet respiration the
\.E 6
Fig. 9. — Diagram of motor path from left brain. The apper segment is black, the lower
red. The nuclei of the motor cerebral nerves are shown on the right side ; on the left
side the cerebral nerves of that side are indicated. A lesion at 1 would cause upper
segment paralysis in the arm of the opposite side — cerebral monoplegia; at 2, upper
segment paralysis of the whole opposite side of the body — hemiplegia ; at 3 (in the crus),
upper segment paralysis of the opposite face, arm, and leg, and lower segment paralysis
of the eye-muscles on the same side — crossed paralysis : at 4 (in the lower part of the
pons), upper segment paralysis of the opposite arm and leg, and lower segment paralysis
of the face and the external rectus on the same side — crossed paralysis ; at 5, upper seg-
ment paralysis of all muscles represented below lesion, and lower segment paralysis of
muscles represented at level of lesion — spinal paraplegia ; at 6, lower segment paralysis
of muscles localized at seat of lesion — anterior poliomyelitis. (Van Gehuchten, modified.)
DIFFUSE AND FOCAL DISEASES OF THE BRAIN. 973
muscles on the paralyzed side acted more strongly than the corresponding
muscles, but that in forced respiration the reverse condition was true. This
has been confirmed by Clark and Bury. The degree of permanent paralysis
after a hemiplegic attack varies much in different cases. When the restitution
is partial, it is always, as Wernicke has pointed out, certain groups of muscles
vhich recover rather than others. Thus in the leg the residual paralysis con-
cerns the flexors of the leg and the dorsal flexors of the- foot — i. e., the muscles
which, according to Ludwig Mann, are active in the second period of walk-
ing, shortening the leg, and bringing it forward while it swings. The mus-
cles which lift the body when the foot rests upon the ground, those used in
the first period of walking, include the extensors of the leg and the plantar
flexors of the foot. These " lengtheners " of the leg often recover almost
completely in cases in which the paralysis is due to lesions of the pyramidal
tract. In the arms the residual paralysis usually affects the muscle groups
which oppose the thumb, those which rotate the arm outward, and the openers
of the hand.
As a rule, there is at first no wasting of the paralyzed limbs.
Crossed Hemiplegia. — A paralysis in which there is loss of function in a
cerebral nerve on one side with loss of power (or of sensation) on the opposite
side of the body is called a crossed or alternate hemiplegia. It is met with
in lesions, commonly haemorrhage, in the crus, the pons, and the medulla
(Fig. 9, 3 and 4).
(a) Crus. — The bleeding may extend from vessels supplying the corpus
striatum, internal capsule, and optic thalamus, or the haemorrhage may be
primarily in the crus. In the classical case of Weber, on section of the lower
part of the left crus an oblong clot 15 mm. in length lay just below the medial
and inferior surface. The characteristic features of a lesion in this locality
are paralysis of arm, face, and leg of the opposite side, and oculo-motor paral-
ysis of the same side — the syndrome of Weber. Sensory changes have also
been present. Haemorrhage into the tegmentum is not necessarily associated
with hemiplegia, but there may be incomplete paralysis of the oculo-motor
nerve, with disturbance of sensation and ataxia on the opposite side of the
body. The optic tract or the lateral geniculate body lying on the lateral side
of the crus may be compressed, in which event there will be hemianopsia.
(b) Pons and Medulla. — Lesions may involve the pyramidal tract and one
or more of the cerebral nerves. If at the lower aspect of the pons, the facial
nerve may be involved, causing paralysis of the face on the same side and
hemiplegia on the opposite side. The fifth nerve may be involved, with the
fillet (the sensory tract), causing loss of sensation in the area of distribution
of the fifth on the same side as the lesion and loss of sensation on the opposite
side of the body. The sensory disturbance here is apt to be dissociated, of
the syringomyelic type, affecting particularly the sense of pain and tem-
perature.
Sensory Disturbances resulting from Cerebral Hcemorrhage. — These are
variable. Hemianaesthesia may coexist with hemiplegia, but in many instances
there is only slight numbing of sensation. When the hemianaesthesia is
marked, it is usually the result of a lesion in the internal capsule involving
the retrolenticular portion of the posterior limb. In C. L. Dana's study of
sensory localization he found that anaesthesia of organic cortical origin was
974 DISEASES OF THE NERVOUS SYSTEM.
always limited or more pronoimced in certain parts, as the face, arm, or leg,
and was generally incomplete. Total anaesthesia was either of functional or
subcortical origin. Marked ansesthesia was much more common in softening
than in hfemorrhage. Complete hemianesthesia is certainly rare in hsemor-
rhage. Disturbance of the special senses is not common. Hemianopia may
exist on the same side as the paralysis, and there may be diminution in
the acuteness of the senses of hearing, taste, and smell. Gowers thinks that
homommious hemianopia of the halves of the visual fields opposite to the
lesion is very frequent shortly after the onset, though often overlooked.
Psychic disturbances, variable in nature and degree, may result from cere-
bral hsemorrhage.
The Reflexes in Apoplectic Cases. — During the apoplectic coma all the
reflexes are abolished, but immediately on recovery of consciousness they
return, first on the non-hemiplegic side, later, sometimes only after weeks,
on the paralyzed side. As to the time of return, especially of the patellar
reflexes, marked differences are observable in individual cases. The deep
reflexes later are increased on the paralyzed side, and ankle clonus may be
present. Plantar stimulation usually gives an extensor response in the great
toe (Babinski's reflex). This may occur very early and is an important indi-
cation of the paralyzed side. The other superficial reflexes are usually dimin-
ished. The sphincters are not affected.
The course of the disease depends upon the situation and extent of the
lesion. If slight, the hemiplegia may disappear completely within a few days
or a few weeks. In severe cases the rule is that the leg gradually recovers
before the arm, and the muscles of the shoulder girdle and upper arm before
those of the forearm and hand. The face may recover quickly.
Except in the very slight lesions, in which the hemiplegia is transient,
changes take place which may be grouped as
SECO]sn)AET Symptoms. — These correspond to the chronic stage. In a
case in which little or no improvement takes place within eight or ten weeks,
it will be found that the paralyzed limbs undergo certain changes. The leg,
as a rule, recovers enough power to enable the patient to get about, although
the foot is dragged. Occasionally a recurrence of severe s}Tnptoms is seen,
even without a new hsemorrhage having taken place. In both arm and leg
the condition of secondary contraction or late rigidity comes on and is always
most marked in the upper extremity. The arm becomes permanently flexed
at the elbow and resists all attempts at extension. The wrist is flexed upon
the forearm and the fingers upgn the hand. The position of the arm and
hand is very characteristic. There is frequently, as the contractures develop,
a great deal of pain. In the leg the contracture is rarely so extreme. The
loss of power is most marked in the muscles of the foot, and to prevent the
toes from dragging, the knee in walking is much flexed, or more conunonly
the foot is swung round in a half-circle.
The reflexes are at this stage greatly increased. These contractures are
permanent and incurable, and are associated with a secondary descending
sclerosis of the motor path. There are instances, however, in which rigidity
and contracture do not occur, but the arm remains flaccid, the leg having
regained its power. This liemiplegie fasque of Bouchard is found most com-
monly m children. Among other secondary changes in late hemiplegia may
DIFFUSE AND FOCAL DISEASES OF THE BRAIN. 975
be mentioned the following: Tremor of the affected limbs, post-paialytic
chorea, the mobile spasm known as athetosis, arthropathies in the joints of
the affected side, and muscular atrophy. Athetosis and post-hemiplegic chorea
will be considered in the hemiplegia of children. The cool surface and thin
glossy skin of a hemiplegic limb are familiar to all. A word may here be
said upon the subject of muscular atrophy of cerebral origin.
As a rule, atrophy is not a marked feature in hemiplegia, but in some
instances it does develop. It has been thought to be due in some cases to
secondary alterations in the gray matter of the ventral horns, as in a case
reported by Charcot. Eecently, however, attention has been called by Senator,
Quincke, and others to the fact that atrophy may follov/ as a direct result of
the cerebral lesion, the ventral horns remaining intact. In Quincke's case,
atrophy of the arm followed the development of a glioma in the anterior cen-
tral convolution. The gray matter of the ventral horns was normal. These
atrophies are most common in cortical lesions involving the domain of the
third main branch of the Sylvian artery, and in central lesions involving the
lenticulo-thalamic region. Their explanation is not clear. The wasting of
cerebral origin, which occurs most frequently in children, and leads to hemi-
atrophy of the muscles along with stunted growth of the bones and joints,
is to be sharply separated from the hemiatrophy of the muscles of the adult
following within a relatively short time upon the hemiplegia.
Diagnosis. — There are three groups of cases which offer increasing diffi-
culty in recognition.
(1) Cases in which the onset is gradual, a day or two elapsing before
the paralysis is fully developed and consciousness completely lost, are readily
recognized, though it may be difficult to determine whether the lesion is due
to thrombosis or to haemorrhage.
(2) In the sudden apoplectic stroke in which the patient rapidly loses
consciousness, the difficulty in diagnosis may be still greater, particularly
if the patient is in deep coma when first seen.
The first point to be decided is the existence of hemiplegia. This may
be difficult, although, as a rule, even in deep coma the limbs on the para-
lyzed side are more flaccid and drop instantly when lifted; whereas, on the
non-paralyzed side the muscles retain some degree of tonus. The reflexes may
be decreased or lost on the affected side and there may be conjugate devia-
tion of the head and eyes. Eigidity in the limbs of one side is in favor of a
hemiplegic lesion. It is practically impossible in a majority of these cases
to say whether the lesion is due to haemorrhage, embolism, or thrombosis.
(3) Large haemorrhage into the ventricles or into the pons may produce
sudden loss of consciousness with complete relaxation, so that the condition
may simulate coma from uraemia, diabetes, alcoholism, opium poisoning, or
epilepsy.
The previous history and the mode of onset may give valuable information.
In epilepsy, convulsions have preceded the coma; in alcoholism, there is a
history of constant drinking, while in opium poisoning the coma develops
more gradually; but in many instances the difficulty is practically very great,
and on more than one occasion I have seen mortifying post-mortem disclosures
under these circumstances. With diabetic coma the breath often smells of
acetone. In ventricular haemorrhage the coma is sudden and develops rapidly.
976 DISEASES OF THE NERVOUS SYSTEM.
The hemiplegic symptoms may be transient, quickly giving place to complete
relaxation. Convulsions occur in many cases, and may be the very symptom
to lead astray — as in a case of ventricular hgemorrhage which occurred in a
puerperal patient, in whom, naturally enough, the condition was thought to be
ursemic. Eigidity is often present. In haemorrhage into the pons convulsions
are frequent. The pupils may be strongly contracted, conjugate deviation may
occur, and the temperature is apt to rise rapidly. The contraction of the
pupils in pontine hsemorrhage naturally suggests opium poisoning. The dif-
ference in temperature in the two conditions is a valuable diagnostic point.
The apoplectiform seizures of general paresis have usually been preceded by
abnormal mental symptoms, and the associated hemiplegia is seldom per-
manent.
It may be impossible at first to give a definite diagnosis. In admissions
to hospitals or in emergency cases the physician should be particularly careful
about the following points : The examination of the head for injury or frac-
ture ; the urine should be tested for albumin, examined for sugar, and studied
microscopically ; a careful examination should be made of the limbs with ref-
erence to their degree of relaxation or the presence of rigidity, and the con-
dition of the reflexes; the state of the pupils should be noted and the tem-
perature taken. The odor of the breath (alcohol, acetone, chloroform, etc.)
should be remarked. The most serious mistakes are made in the case of
patients who are drunk at the time of the attack, a combination by no means
uncommon in the class of patients admitted to hospital. Under these circum-
stances the case may erroneously be looked upon as one of alcoholic coma. It
is best to regard each case as serious and to bear in mind that this is a
■condition in which, above all others, mistakes are common.
Prognosis. — From cortical hsemorrhage, unless very extensive, the recovery
may be complete without a trace of contracture. This is more common when
the hsemorrhage follows injury than when it results from disease of the
arteries. Infantile meningeal hgemorrhage, on the other hand, is a condition
which may produce idiocy or spastic diplegia.
Large haemorrhages into the corona radiata, and especially those which
rupture into the ventricles, rapidly prove fatal.
The hemiplegia which follows lesions of the internal capsule, the result
of rupture of the lenticulo-striate artery, is usually persistent and followed
by contracture. When the retro-lenticular fibres of the internal capsule are
involved there may be hemianaesthesia, and later, especially if the thalamus
he implicated, hemichorea or athetosis. In any case of cerebral apoplexy the
following symptoms are of grave omen: persistence or deepening of the coma
during the second and third day; rapid rise in temperature within the first
forty-eight hours after the initial fall. In the reaction which takes place on
the second or third day, the temperature usually rises, and its gradual fall
on the third or fourth day with return of consciousness is a favorable indica-
tion. The rapid formation of bed-sores, particularly the malignant decubitus
of Charcot, is a fatal indication. The occurrence of albumin and sugar, if
abundant, in the urine is an unfavorable symptom.
When consciousness returns and the patient is improving, the question is
anxiously asked as to the paralysis. The extent of this can not be determined
for some weeks. With slight lesions it may pass ofi entirely. If persistent at
DIFFUSE AND FOCAL DISEASES OF THE BRAIN. 977
the end of a month some grade of permanent palsy is certain to remain, and
gradually the late rigidity supervenes.
5. Embolism and Theombosis {Cerebral Softening).
(a) Embolism. — The embolus usually enters the carotid, rarely the verte-
bral artery. In the great majority of cases it comes from the left heart and
is either a vegetation of a fresh endocarditis or, more commonly, of a recurring
endocarditis, or from the segments involved in an ulcerative process. Less
often the embolus is a portion of a clot which has formed in the auricular
appendix. Portions of clot from an aneurism, thrombi from atheroma of the
aorta, or from the territory of the pulmonary veins, may also cause blocking
of the branches of the circle of Willis. In the puerperal condition cerebral
embolism is not infrequent. It may occur in women with heart-disease, but
in other instances the heart is uninvolved, and the condition has been thought
to be associated with the development of heart-clots, owing to increased coagu-
lability of the blood. A majority of cases of embolism occur in heart-disease,
89 per cent (Saveliew). Cases are rare in the acute endocarditis of rheuma-
tism, chorea, and febrile conditions. It is much more common in the secondary
recurring endocarditis which attacks old sclerotic valves. The embolus most
frequently passes to the left middle cerebral artery, as it enters the left carotid
oftener than the right because of the more direct course of the blood in the
former. The posterior cerebral and the vertebral are less often affected. A
large plug may lodge at the bifurcation of the basilar. Embolism of the
cerebellar vessels is rare.
Embolism occurs more frequently in women, owing, no doubt, to the greater
frequency of mitral stenosis. Contrary to this general statement, I^ewton
Pitt's statistics of 79 cases at Guy's Hospital indicate, however, that males are
more frequently affected; or in this series there were 44 males and 35 females.
Saveliew gives 54 per cent in women.
(&) Thrombosis. — Clotting of blood in the cerebral vessels occurs (1) about
an embolus, (2) as the result of a lesion of the arterial wall (either endar-
teritis with or without atheroma or, particularly, the syphilitic arteritis), (3)
in aneurisms both coarse and miliary, and (4) very rarely as a direct result
of abnormal conditions of the blood. Thrombosis occasionally follows ligation
of the carotid artery. The thrombosis is most common in the middle cerebral
and in the basilar arteries. According to Kolisko, softening of limited areas,
sufficient to induce hemiplegia, may be caused by sudden collapse of certain
cerebral arteries from cardiac weakness.
Anatomical Changes. — Degeneration and softening of the territory sup-
plied by the vessels is the ultimate result in both embolism and thrombosis.
Blocking in a terminal artery may be followed by infarction, in which the
territory may either be deeply infiltrated with blood (hgemorrhagic infarction)
or be simply pale, swollen, and necrotic (anaemic infarction). Gradually the
process of softening proceeds, the tissue is infiltrated with serum and is moist,
the nerve fibres degenerate and become fatty. The neuroglia is swollen and
cedematous. The color of the softened area depends upon the amount of blood.
The haemoglobin undergoes gradual transformation, and the early red color
may give place to yellow. Formerly much stress was laid upon the difference
63
978 DISEASES OF THE NERVOUS SYSTEM.
between red, yellow, and white softening. The red and yellow are seen chiefly
on the cortex. Sometimes the red softening is particularly marked in cases
of embolism and in the neighborhood of tumors. The gray matter shows many
punctiform haemorrhages — capillary apoplexy. There is a variety of yellow
softening — the plaques jaunes — common in elderly persons, which occurs in
the gray matter of the convolutions. The spots are from 1 to 2 cm. in diam-
eter, sometimes are angular in shape, the edges cleanly cut, and the softened
area is represented by either a turbid, yellow material, or in some instances
there is a space crossed by fine trabecule, in the meshes of which there is fluid.
White softening occurs most frequently in the white matter, and is seen best
about tumors and abscesses. Inflammatory changes are common in and about
the softened areas. When the embolus is derived from an infected focus, as
in ulcerative endocarditis, suppuration may follow. The final changes vary
very much. The degenerated and dead tissue elements are gradually but slowly
removed, and if the region is small may be replaced by a growth of connective
tissue and the formation of a scar. If large, the resorption results in the
formation of a cyst. It is surprising for how long an area of softening may
persist without much change.
The position and extent of the softening depend upon the obstructed artery.
An embolus which blocks the middle cerebral at its origin involves not only
the arteries to the anterior perforated space, but also the cortical branches, and
in such a case there is softening in the neighborhood of the corpus striatum,
as well as in part of the region supplied by the cortical vessels. The freedom
of anastomosis between these branches varies a good deal. Thus, there are
instances of embolism of the middle cerebral artery in which the softening
has involved only the territory of the central branches, in which case blood has
reached the cortex through the anterior and posterior cerebrals. When the
middle cerebral is blocked (as is perhaps oftenest the case) beyond the point
of origin of the central arteries, one or other of its branches is usually most
involved. The embolus may lodge in the vessel passing to the third frontal
convolution, or in the artery of the ascending frontal or ascending parietal;
or it may lodge in the branch passing to the supramarginal and angular gyri,
or it may enter the lowest branch which is distributed to the upper convolu-
tions of the temporal lobe. These are practically terminal arteries, and in-
stances frequently occur of softening limited to a part, at any rate, of the
territory supplied by them. Some of the most accurate focalizing lesions are
produced in this way.
Symptoms. — Extensive thrombotic softening may exist without any sjrmp-
toms. It is not uncommon in the post-mortem examination of the bodies of
elderly persons to find the plaques jaunes scattered over the convolutions. So,
too, softening may take place in the " silent " regions, as they are termed,
without exciting any s3rmptoms. When the central or cortical branches of the
middle cerebral arteries are involved the symptoms are similar to those of
haemorrhage from the same arteries. Permanent or transient hemiplegia re-
sults. When the central arteries are involved the softening in the internal
capsule is commonly followed by permanent hemiplegia. There are certain
peculiarities associated with embolism and with thrombosis respectively.
In emholism the patient is usually the subject of heart-trouble, or there
exist some of the conditions already mentioned. The onset is sudden, without
DIFFUSE AND FOCAL DISEASES OF THE BRAIN. 979
premonitory symptoms. When the embolus blocks the left middle cerebral
artery the hemiplegia is usually associated with aphasia. In thrombosis, on
the other hand, the onset is more gradual; the patient has previously com-
plained of headache, vertigo, tingling in the j&ngers ; the speech may have been
embarrassed for some days; the patient has had loss of memory or is inco-
herent, or paralysis begins at one part, as the hand, and extends slowly, and
the hemiplegia may be incomplete or variable. Abrupt loss of consciousness
is much less common, and when the lesion is small consciousness is retained.
Thus, in thrombosis due to syphilitic disease, the hemiplegia may come on
gradually without the slightest disturbance of consciousness.
The hemiplegia following thrombosis or embolism has practically the char-
acteristics, both primary and secondary, described under haemorrhage.
The following may be the effects of blocking the different vessels: (a)
Vertebral. — The left branch is more frequently plugged. The effects are in-
volvement of the nuclei in the medulla and symptoms of acute bulbar paralysis.
It rarely occurs alone ; more commonly with
(&) Blocking of the basilar artery. When this- is entirely occluded, there
may be bilateral paralysis from involvement of both motor paths. Bulbar
symptoms may be present; rigidity or spasm may occur. The temperature
may rise rapidly. The symptoms, in fact, are those of apoplexy of the pons.
(c) The posterior cerebral supplies the occipital lobe on its medial surface
and the greater part of the temporo-sphenoidal lobe. If the main stem be
thrombosed there is hemianopia with sensory aphasia. Localized areas of
softening may exist without symptoms. Blocking of the main occipital branch
(arteria occipitalis of Duret), or of the arteria calcarina, passing to the cuneus
may be followed by hemianopia. Hemiansesthesia may result from involve-
ment of the posterior part of the internal capsule. Not infrequently symmet-
rical thrombosis of the occipital arteries of the two sides occurs, as in Forster's
well-known case. Still more frequent is the occurrence of thrombosis of a
branch of the posterior cerebral of one hemisphere and a branch of the middle
cerebral of the other (von Monakow). It is in such cases that the most
pronounced instances of apraxia are met with.
(d) Internal Carotid. — The symptoms are variable. As is well known, the
vessel is in a majority of cases ligated without risk. In other instances tran-
sient hemiplegia follows ; in others again the hemiplegia is permanent. These
variations depend on the anastomoses in the circle of Willis. If these are
large and free, no paralysis follows, but in cases in which the posterior com-
municating and the anterior communicating vessels are small or absent, the
paralysis may persist. In No. 7 of my Elwyn series of cases of infantile hemi-
plegia, the woman, aged twenty-four, when six years old, had the right carotid
ligated for abscess following scarlet fever, with the result of permanent hemi-
plegia. Blocking of the internal carotid within the skull by thrombosis or
embolism is followed by hemiplegia, coma, and usually death. The clot is
rarely confined to the carotid itself, but spreads into its branches and may
involve the ophthalmic artery.
(e) Middle Cerebral. — This is the vessel most commonly involved, and, as
already mentioned, if plugged before the central arteries are given off, perma-
nent hemiplegia usually follows from softening of the internal capsule. Block-
ing of the branches beyond this point may be followed by hemiplegia, which
980 DISEASES OF THE NERVOUS SYSTEM.
is more likel}' to be transient, involves chiefly tlie arm and face, and if the
lesion be on the left side is associated with aphasia. There ma}^ be plugging
of the individual branches passing to the inferior frontal (producing typical
motor aphasia if the disease be on the left side), to the anterior and posterior
central gyri (usually causing total hemiplegia), to the supramarginal and
angular gyri (giving rise, if the thrombosis be on the left side, probably with-
out exception to the so-called visual aphasia (alexia), usually also to right-
sided hemianopsia), or to the temporal gyri (in which event with left-sided
thrombosis word-deafness results).
(/) Anterior Cerebral. — Xo symptoms may follow, and even when the
branches which supply the paracentral lobule and the top of the ascending
convolutions are plugged the branches from the middle cerebral are usually
able to effect a collateral circulation in these parts. Monoplegia of the leg
may, however, result. Hebetude and dulness of intellect may occur with
obstruction of the vessel.
There is unquestionably greater freedom of communication in the cortical
branches of the different arteries than is usually admitted, although it is not
possible, for example, to inject the posterior cerebral through the middle cere-
bral, or the middle cerebral from the anterior; but the absence of softening
in some instances in which smaller branches are blocked shows how complete
may be the compensation, probably by way of the capillaries. The dilatation
of the collateral branches may take place very rapidly; thus a patient with
chronic nephritis died about twenty-four hours after the hemiplegic attack.
There were recent vegetations on the mitral valve and an embolus in the right
middle cerebral artery just beyond the first two branches. The central portion
of the hemisphere was swollen and oedematous. The right anterior cerebral
was greatly dilated, and by measurement its diameter was found to be nearly
three times that of the left.
Treatment of Cerebral Haemorrhage and of Softening. — The chief difficulty
in deciding upon a method of treatment is to determine whether the apoplexy
is due to hsemorrhage or to thrombosis "or embolism. The patient should be
placed in bed, with his head moderately elevated and the neck free. He should
be kept absolutely quiet. If there is dj^spncea, stertor, and signs of mechanical
obstruction to respiration, he should be turned on his side, as recommended
by Bowles. This procedure also lessens the liability to congestion of the lungs.
If the signs of intracranial haemorrhage are certain, and if the arterial tension
is high, measures may be taken for its reduction. Of these the most rapid
and satisfactory is venesection, which in many cases seems to do good. How-
ever, as Gushing has shown exj)erimentally, a rapid and increasing rise of
arterial tension, usually indicates an endeavor of the vasomotor centres to
counteract an increasing intracranial pressure, in this case due to a continuing
hsemorrhage. The indication under these circumstances is the relief of the
intracranial pressure by craniotomy and removal of the clot, if this is possible.
This is particularly applicable in subdural haemorrhage. Horsley and Spencer
have recently, on experimental grounds, recommended the practice, formerly
employed empirically, of compression of the carotid, particularly in the in-
gravescent form ; or even, in suitable cases, passing a ligature round the vessel.
An ice-bag may be placed on the head and hot bottles to the feet. The bowels
should be freely opened, either by calomel, or croton oil placed on the tongue.
DIFFUSE AND FOCAL DISEASES OF THE BRAIN. 981
Counter-irritation to the neck or to the feet is not necessary. Catheterization
of the bladder may be necessary, especially if the patient remain long uncon-
scious.
Special care should be taken to avoid bed-sores; and if bottles are used
to the feet, they should not be too hot, since blisters may be readily caused
by a much lower temperature than in health. In the fever of reaction, aconite
may be indicated, but should be cautiously used. Stimulants are not necessary,
unless the pulse becomes feeble and signs of collapse supervene. No digitalis
is to be given. During recovery the patient should be still kept entirely at rest,
even in the mildest cases remaining in bed for at least fourteen days. The
ice-bag should still be kept at the head. The diet should be light and no
medicine other than some placebo should be administered, at least during the
first month after the haemorrhage. Attention should be paid to the position
occupied by the paralyzed limb or limbs, which if swollen may be wrapped in
cotton batting or flannel.
The treatment of softening from thrombosis or embolism is very unsatis-
factory. Venesection is not indicated, as it lowers the tension and rather
promotes clotting. If, as is often the case, the heart's action is feeble and
irregular, stimulants and small doses of digitalis may be given with, if neces-
sary, ether or ammonia. The bowels should be kept open, but it is not well
to purge actively, as in haemorrhage.
In the thrombosis which follows syphilitic disease of the arteries, and which
is met with most frequently in men between twenty and forty (in whom' the
hemiplegia often sets in without loss of consciousness), the iodide of potassium
should be freely used, giving from 20 to 30 grains three times a day, or, if
necessary, larger doses. If the syphilis has been recent, mercurials by inunc-
tion are also indicated. Practically these are the only cases of hemiplegia in
which we see satisfactory results from treatment.
Very little can be done for the hemiplegia which remains. The damage
is too often irreparable and permanent, and it is very improbable that iodide
of potassium, or any other remedy, hastens in the slightest degree ISTature's
dealing with the blood-clot.
The paralyzed limbs may be gently rubbed once or twice a day, and this
should be systematically carried out, in order to maintain the nutrition of the
muscles and to prevent, if possible, contractures. The massage should not,
however, be begun until at least ten days after the attack. The rubbing should
be toward the body, and should not be continued for more than fifteen minutes
at a time. After the lapse of a fortnight, or in severe cases a month, the mus-
cles may be stimulated by the f aradic current ; f aradic stimulation alternating
with massage, especially if applied to the antagonists of the muscles which
ordinarily undergo contracture, is of very great service, even in cases where
there can be but little hope of any return of voluntary movement. 'V\nien con-
tractures occur, electricity properly applied at intervals may still be of some
benefit along with the passive movements and frictions, and it has been sug-
gested that tendon transplantation, or indeed cross suture of nerves, may cause
some improvement.
In a case of complete hemiplegia, the friends should at the outset be
frankly told that the chances of full recovery are slight.. Power is usually re-
stored in the leg sufficient to enable the patient to get about, but in the major-
982 DISEASES OF THE NERVOUS SYSTEAI.
ity of instances the finer movements of the liand are permanently lost. The
general health should be looked after, the bowels regulated, and the secretions
of the skin and kidne3^s kept active. In permanent hemiplegia in persons
above the middle period of life, more or less mental weakness is apt to follow
the attack, and the patient may become irritable and emotional.
And, lastly, when hemiplegia has persisted for more than three months and
contractures have developed, it is the duty of the physician to explain to the
patient, or to his friends, that the condition is past relief, that medicines and
electricity will do no good, and that there is no possible hope of cure.
6. AXEUEISM OF THE CeEEBEAL AeTEEIES.
Miliary aneurisms are not included, but reference is made only to aneurism
of the larger branches. The condition is not uncommon. There were 13
instances in my first 800 autopsies in Montreal.* This is a considerably larger
proportion than in Newton Pitt's collection from Guy's Hospital, 19 times in
9,000 inspections.
Etiology. — Males are more frequently affected than females. Of my 12
cases 7 were males. The disease is most common at the middle period of life.
One of my cases was a lad of six. Pitt describes one at the same age. The
chief causes are (a) endarteritis, either simple or syphilitic, which leads to
weakness of the wall and dilatation; and (5) embolism. As pointed out by
Church, these aneurisms are often found with endocarditis. Pitt, in his recent
study of the subject, concludes that it is exceptional to find cerebral aneurism
unassociated with fungating endocarditis. The embolus disappears, and dila-
tation follows the secondary inflammatory changes in the coats of the vessel.
Morbid Anatomy. — The middle cerebral branches are most frequently in-
volved. In my 12 cases the distribution on the arteries was as follows : Inter-
nal carotid, 1 ; middle cerebral, 5 ; basilar, 3 ; anterior communicating, 3. Ex-
cept in one case they were saccular and communicated with the lumen of the
vessel by an orifice smaller than the circumference of the sac. In the 154
cases which make up the statistics of Lebert, Durand, and Bartholow the mid-
dle cerebral was involved in 44, the basilar in 41, internal carotid in 23, ante-
rior cerebral in 14, posterior communicating in 8, anterior communicating in 8,
vertebral in 7, posterior cerebral in 6, inferior cerebellar in 3 (Gowers). The
size of the aneurism varies from that of a pea to that of a walnut. The haem-
orrhage may be entirely meningeal with very slight laceration of the brain
substance, but the bleeding may be, as Coats has shown, entirely within the
substance.
Symptoms. — The aneurism may attain considerable size and cause no
symptoms. In a majority of the cases the first intimation is the rupture and
the fatal apoplexy. Distinct symptoms are most frequently caused by aneu-
rism of the internal carotid, which may compress the optic nerve or the com-
missure, causing neuritis or paralysis of the third nerve. A murmur may be
audible on auscultation of the skull. x\neurism in this situation may give rise
to irritative and pressure symptoms at the base of the brain or to hemianopsia.
In the remarkable case reported by Weir Mitchell and Dercum an aneurism
compressed the chiasma and produced bilateral temporal hemianopsia.
* Canada Medical and Surgical Journal, vol. xiv.
DIFFUSE AND FOCAL DISEASES OF THE BRAIN. 983
Aneurism of the vertebral or of the basilar may involve the nerves from
the fifth to the twelfth. A large sac at the termination of the basilar may-
compress the third nerves or the crura.
The diagnosis is, as a rule, impossible. The larger sacs produce the symp-
toms of tumor, and their rupture is usually fatal.
7. Endarteritis.
In no group of vessels do we more frequently see chronic degenerative
changes than in those of the circle of Willis. The condition occurs as :
(a) Arterio-sclerosis, producing localized or diffused thickening of the
intima with the formation of atheromatous patches or areas of calcification.
In the later stages, as seen in elderly people, the arteries of the circle of Willis
may be dilated, stiff, or almost universally calcified.
(h) Syphilitic Endarteritis. — As already mentioned under the section of
syphilis, gummatous endarteritis is specially prone to attack the cerebral ves-
sels. It has in itself no specific characters — that is to say, it is impossible in
given sections to pick out an endarteritis syphilitica from an ordinary endar-
teritis obliterans. On the other hand, as already stated, the nodular peri-
arteritis is never seen except in syphilis.
8. Thrombosis of the Cerebral Sinuses and Veins.
The condition may be primary or secondary. Lebert (1854) and Tonnele
were among the first to recognize the condition clinically.
Primary thrombosis of the sinuses and veins is rare. It occurs (a) in
children, particularly during the first six months of life, usually in connec-
tion with diarrhcea. It has, in my experience, been a rare condition. I have
never seen an example of spontaneous thrombosis of the sinuses in a child,
and only two instances, both in connection with meningitis, in which the cor-
tical veins contained clots. Gowers believes that it is of frequent occurrence,
and that thrombosis of the veins is not an uncommon cause of infantile hemi-
plegia.
(h) In connection with chlorosis and ansemia, the so-called autochthonous
sinus-throm,hosis. Of 83 cases of thrombosis in chlorosis, 78 were in the veins
and 33 in the cerebral sinuses. The longitudinal sinus is most frequently
involved. The thrombosis is usually associated with venous thromboses in
other parts of the body, and the patients die, as a rule, in from one to three
weeks, but both Bristowe and Buzzard report recoveries.
(c) In the terminal stages of cancer, phthisis, and other chronic diseases
thrombosis may gradually occur in the sinuses and cortical veins. To the
coagulum developing in these conditions the term marantic thrombus is
applied.
Secondary thrombosis is much more frequent and follows extension of
infiammation from contiguous parts to the sinus wall. The common causes
are disease of the internal ear, fracture, compression of the sinuses by tumor,
or suppurative disease outside the skull, particularly erysipelas, carbuncle, and
parotitis. In secondary cases the lateral sinus is most frequently involved.
Of 57 fatal cases in which ear-disease caused death with cerebral lesions, there
were 33 in which thrombosis existed in the lateral sinuses (Pitt). Tubercu-
984 DISEASES OF THE NERVOUS SYSTEM.
Ions caries of the temporal bone is often directly responsible. The thrombus
ma}^ be small, or may fill the entire sinus and extend into the internal jugular
vein. In more than one-half of these instances the thrombus was suppurat-
ing. The disease spreads directly from the necrosis on the posterior wall of
the tjonpanum. According to Yoltolini, the inflammation extends by way of
the petroso-mastoid canal. It is not so common in disease of the mastoid
cells.
Symptoms. — Primary tJiromhosis of the longitudinal sinus may occur with-
out exciting sjonptoms and is found accidentall}^ at the post mortem. There
may be mental dulness with headache. Convulsions and vomiting may occur.
In other instances there is nothing distinctive. In a patient who died under
my care, at the Philadelphia Hospital, of phthisis, there was a gradual tor-
por, deepening to coma, without convulsions, localizing symptoms, or optic
neuritis. The condition was thought to be due to a terminal meningitis. In
the chlorosis eases the head symptoms have, as a rule, been marked. Ball's
patient was dull and stupid, had vomiting, dilatation of the pupils, and double
choked disks. Slight paresis of the left side occurred. An interesting feature
in this case was the development of swelling of the left leg. In the cases
reported by Andrews, Church, Tuckwell, Isambard Owen, and Wilks the
patients had headache, vomiting, and delirium. Paralysis was not present.
In Douglas Powell's case, with similar symptoms, there was loss of power on
the left side. Bristowe reports a case of great interest in an ansmic girl of
nineteen, who had convulsions, drowsiness, and vomiting. Tenderness and
swelling developed in the position of the right internal jugular vein, and a
few days later on the opposite side. The diagnosis was rendered definite by
the occurrence of phlebitis in the veins of the right leg. The patient recovered.
The onset of such symptoms as have been mentioned in an anaemic or
chlorotic girl should lead to the suspicion of cerebral thrombosis. In infants
the diagnosis can rarely be made. Involvement of the cavernous sinus may
cause oedema about the eyelids or prominence of the eyes.
In the secondary tliromhi the S3miptoms are commonly those of septi-
cgemia. Por instance, in over 70 per cent of Pitt's cases the mode of death
was by pulmonary pysemia. Tliis author draws the following important con-
elusions: (1) The disease spreads oftener from the posterior wall of the
middle ear than from the mastoid cells. (2) The otorrhoea is generally of
some standing, but not always. (3) The onset is sudden, the chief symp-
toms being pyrexia, rigors, pains in the occipital region and in the neck,
associated with a septicemic condition. (4) Well-marked optic neuritis may
be present. (5) The appearance of acute local pulmonary mischief or of
distant suppuration is almost conclusive of thrombosis. (6) The average
duration is about three weeks, and death is generally from pulmonary pysemia.
The chief points in the diagnosis may be gathered from these statements.
Pitt records an interesting case of recovery in a boy of ten, who had otor-
rhoea for 3"ears and was admitted with fever, earache, tenderness, and oedema.
A week later he had a rigor, and optic neuritis developed on the right side.
The mastoid was explored unsuccessfully. The fever and cllills persisting,
two days later the lateral sinus was explored. A mass of foul clot was re-
moved and the jugular vein was tied, after which the boy made a satisfactory
recovery.
1
DIFFUSE AND FOCAL DISEASES OF. THE BRAIN. 985
According to Griesingor there is often associated with throinl)osis of the
lateral sinus venous stasis and painful oedema behind the ear and in the neck.
The external jugular vein on the diseased side may be less distended than on
the opposite side, since owing to the thrombus in the lateral sinus the internal
jugular vein is less full than on the normal side, and the blood from the exter-
nal jugular can flow more easily into it (Gerhardt) .
Treatment. — In marantic individuals roborants and stimulants are indi-
cated. The position assumed in bed should favor both the arterial and venous
circulation. The clothing should not restrict the neck, and care should be
taken to avoid bending of the neck.
The internal administration of potassium iodide and calomel has been
recommended in the autochthonous forms, but no treatment is likely to be
of any avail.
The secondary forms, especially those following upon disease of the middle
ear, are often amenable to operation, and, especially recently, many lives have
been saved by surgical intervention after extensive sinus thrombosis. Mac-
ewen's book on Pyogenic Infective Diseases of the Brain and Spinal Cord
contains the most exhaustive presentation of the subject of sinus thrombosis
and its treatment.
9. Hemiplegia in Childeen.
Etiology. — Of 135 cases, 60 were in boys and 75 in girls. Eight hemi-
plegia occurred in 79, left in 56. In 15 cases the condition was said to be
congenital.
In a great majority the disease sets in during the first or second year;
thus of the total number of cases, 95 were under two. Cases above the fifth
year are rare, only 10 in my series. Neither alcoholism nor syphilis in the
parents appears to play an important role in this affection. Difficult or abnor-
mal labor is responsible for certain of the cases, particularly injury with the
forceps. Trauma, such as falls or puncturing wounds, is more rare. The
condition followed ligation of the common carotid in one case.
Infectious diseases. All the authors lay special stress upon this factor. In
19 cases in my series the disease came on during or just after one of the spe-
cific fevers. I saw one case in which during the height of vaccination con-
vulsions developed, followed by hemiplegia. In a great majority of the cases
the disease sets in with a convulsion, in which the child may remain for sev-
eral hours or longer, and after recovery the paralysis is noticed.
Morbid Anatomy. — In an analysis which I have made of 90 autopsies
reported in the literature, the lesions may be grouped under three headings :
(a) Embolism, thrombosis, and haemorrhage, comprising 16 cases, in 7 of
which there was blocking of a Sylvian artery, and in 9 haemorrhage. A strik-
ing feature in this group is the advanced age of onset. Ten of the cases
occurred in children over six years old.
(&) Atrophy and sclerosis, comprising 50 cases. The wasting is either of
groups of convolutions, an entire lobe, or the whole hemisphere. The meninges
are usually closely adherent over the affected region, though sometimes they
look normal. The convolutions are atrophied, firm, and hard, contrasting
strongly with the normal gyri. The sclerosis may be diffuse and wide-spread
over a hemisphere, or there may be nodular projections — the hypertrophic scle-
64
986 DISEASES OF THE NERVOUS SYSTEM.
rosis. Some of the cases show remarkable unilateral atrophy of the hemi-
sphere. In one of my cases the atrophied hemisphere weighed 169 grammes
and the normal one 653 grammes. The brain tissue may be a mere shell over
a dilated ventricle.
(c) PorencejDhalus, which was present in 2i of the 90 autopsies. This tejm
was applied by Heschel (1868) to a loss of substance in the form of cavities
and cysts at the surface of the brain, either opening into and bounded by the
araclinoid, and even passing deeply into the hemisphere, or reaching to the
ventricle. In the study by Audrey of 103 cases of porencephalus. hemiplegia
was mentioned in 68 cases.
Practically, then, in infantile hemiplegia cortical sclerosis and porenceph-
alus are the important anatomical conditions. The primary change in the
majorit}" of these cases is still unknown. Porencephalus may result from a
defect in development or from haemorrhage at birth. The etiology is clear in
the limited number of cases of haemorrhage, embolism, and thrombosis, but
there remains the large group in which the final change is sclerosis and atro-
phy. What is the primary lesion in these instances? The clinical history
shows that in nearly aU these cases the onset is sudden, with convulsions —
often with slight fever. Striimpell believes that this condition is due to an
inflammation of the gray matter — poliencephalitis — a view which has not
been very widely accepted, as the anatomical proofs are wanting. Gowers sug-
gests that thrombosis may be present in some instances. This might probably
account for the final condition of sclerosis, but clinically thrombosis of the
veins rarely occurs in healthy children, which appear to be those most fre-
quently attacked by infantile hemiplegia, and post-mortem proof is yet want-
ing of the association of thrombosis with the disease.
Symptoms. — (a) The oxset. The disease may set in suddenly without
spasms or loss of consciousness. In more than half the cases the child is
attacked with partial or general convulsions and loss of consciousness, which
may last from a few hours to many days. This is one of the most striking
features in the disease. Fever is usually present. The hemiplegia, noticed as
the child recovers consciousness, is generally complete. Sometimes the paraly-
sis is not complete at first, but develops after subsequent convulsions. The
right side is more frequently affected than the left. The face is commonly not
involved.
(&) PiESiDUAL SYMPTOMS. In some cases the paralysis gradually disap-
pears and leaves scarcely a trace as the child grows up. The leg, as a rule,
recovers more rapidly and more fully than the arm, and the paralysis ma}^ be
scarcely noticeable. In a majority of cases, however, there is a characteristic
hemiplegic gait. The paralysis is most marked in the arm, which is usually
wasted ; the forearm is flexed at right angles, the hand is flexed, and the fingers
are contracted. ]\Iotion may be almost completely lost; in other instances the
arm can be lifted above the head. Late rigidity, which almost always develops,
is the symptom which suggested the name hemiplegia spastica cerehralis to
Heine, the orthopaedic surgeon, who first accurately described these eases. It
is, however, not constant. The limbs may be quite relaxed even years after
the onset. The reflexes are usually increased. In several instances, however,
I have known them to be absent. Sensation, as a rule, is not disturbed.
Aphasia is a not tmcommon symptom, and occurred in 16 cases of my
DIFFUSE AND FOCAL DISEASES OF THE BRAIN. 987
series — a smaller number than that given in the series of Wallenberg, Gau-
dard, and Sachs.
Mental Defects. — One of the most serious consequences of infantile hemi-
plegia is the failure of mental development. A considerable number of these
cases drift into the institutions for feeble-minded children. Three grades
may be distinguished — idiocy, which is most common when the hemiplegia
has existed from birth; imbecility, which often increases with the develop-
ment of epilepsy; and feeble-mindedness, a retarded rather than an arrested
development.
Epilepsy. — Of the cases in my series, 41 were subjects of convulsive seiz-
ures, one of the most distressing sequels of the disease. The seizures may be
either transient attacks of petit mal, true Jacksonian fits, beginning in and
confined to the affected side, or general convulsions.
Post-hemiplegic Movements. — It was in cases of this sort that Weir
Mitchell first described the post-hemiplegic movements. They are extremely
common, and were present in 34 of my series. There may be either slight
tremor in the affected muscles, or incoordinate choreiform movements — the
so-called post-hemiplegic chorea — or, lastly.
Athetosis. — In this condition, described by Hammond, there are remark-
able spasms of the paralyzed extremities, chiefly of the fingers and toes, and
in rare instances of the muscles of the mouth. The movements are involun-
tary and somewhat rhythmical ; in the hand, movements of adduction or abduc-
tion and of supination and pronation follow each other in orderly sequence.
There may be hyperextension of the fingers, during which they are spread
wide apart. This condition is much more frequent in children than in adults.
In the latter it may be combined with hemiangesthesia, and the lesion is not
cortical, but basic in the neighborhood of the thalamus. The movements are
sometimes increased by emotion. They usually persist during sleep.
■ Treatment. — The possibility of injury to the brain in protracted labor and
in forceps cases should be borne in mind by the practitioner. The former
entails the greater risk. In infantile hemiplegia the physician at the outset
sees a case of ordinary convulsions, perhaps more protracted and severe than
usual. These should be checked as rapidly as possible by the use of the
bromides, the application of cold or heat, and a brisk purge. During convul-
sions' chloroform may be administered with safety even to the youngest chil-
dren. When the paralysis is established not much can be hoped from medi-
cines. In only rare instances does the paralj^sis entirely disappear. When the
recovery is partial the " residual paralysis " is similar to that seen in other
lesions of the upper motor segment. Thus in the lower extremity it is the
flexors of the leg and the dorsal flexors of the foot which are most often per-
manently paralyzed (Wernicke). The indications are to favor the natural
tendency to improve by maintaining the general nutrition of the child, to
lessen the rigidity and contractures by massage and passive motion, and if
necessary to correct deformities by mechanical or surgical measures. Much
may be done by careful manipulation and rubbing and the application of a
proper apparatus. In children the aphasia usually disappears. The epi-
lepsy is a distressing and obstinate symptom, for which a cure can rarely be
anticipated. Prolonged periods of quiescence are, however, not uncommon. In
the Jacksonian fits the bromides rarely do good, unless there is much irritabil-
988 DISEASES OF THE NERVOUS SYSTEM.
ity and excitement. Operative measures in favorable cases of this particular
form of epilepsy may often prove beneficial in reducing the number and severity
of the seizures, but it is very unusual for them to be completely or permanently
checked. The liability to feeble-mindedness is the most serious outlook in the
infantile cerebral palsies. In many cases the damage is irreparable, and idiocy
and imbecility result. With patient training and with care many of the chil-
dren reach a fair measure of intelligence and self-reliance.
IV. TUMORS, INFECTIOUS GRANULOMATA, AND
CYSTS OF THE BRAIN.
The following are the most common varieties of new growths within the
cranium :
(1) Infectious Granulomata. — (a) Tubercle^ which may form large or
small growths, usually multiple. Tuberculosis of the glands or bones may
be coexistent, but the tuberculous disease of the brain may occur in the absence
of other clinically recognizable tuberculous lesions. The disease is most fre-
quent early in life. Three-fourths of the cases occur under twenty, and one-
half of the patients are under ten years of age (Gowers). Of 300 cases of
tumor in persons under nineteen collected from various sources by Starr, 153
were tubercle. The nodules are most numerous in the cerebellum and about
the base.
(&) Sypliiloma is most commonly found on the cortex cerebri or about the
pons. The tumors are superficial, attached to the arteries or the meninges,
and rarely grow to a large size. They may be multiple. The motor nerves
of the eye are particularly prone to sj-philitic infiltration, and ptosis and the
ordinary forms of squint are common.
(2) Tumors. — (c) Glioma and Neuroglioma. — These vary greatly in ap-
pearance. They may be firm and hard, almost like an area of sclerosis, or
soft and very vascrdar. Haemorrhages are apt to occur in them. They per-
sist remarkably for many years. Klebs has called attention to the occurrence
of elements in them not unlike ganglion-cells. Tumors of this character may
contain the " Spinnen " or spider cells ; enormous spindle-shaped cells with
single large nuclei; cells like the ganglion-cells of nerve-centres with nuclei
and one or more processes; and translucent, band-like fibres, tapering at each
end, which result from a vitreous or hyaline transformation of the large spin-
dle-cells. A separate type is also recognizable, in which the cells resemble the
ependymal epithelium.
(d) Sarcoma occurs most commonly in the membranes covering the hemi-
spheres or brain stem, and for a long time may cause injury by its compres-
sion effects alone. Tumors of this kind are particularly common in the cere-
bello-pontine recess. When sarcoma originates in the brain substance it may
become one of the largest and most diffusely infiltrating of intracranial
growths. Sarcoma is usually a primary growth and occurs next in frequency
to tubercle. When meningeal in origin, it is the form of tumor most amenable
to surgical treatment.
(e) Carcinoma not infrequently is secondary to cancer in other parts. It
is seldom primary. Occasionally cancerous tumors have been found in sym-
metrical parts of the brain.
DIFFUSE AND FOCAL DISEASES OF THE BRAIN. 989
(/') Other varieties occur, such as fibroid growths, which usually develop
from the membranes; bony tumors, which grow sometimes from the falx,
psammona, cholesteatoma, and angioma. Fatty tumors are occasionally found
on the corpus callosum.
(3) Cysts. — (g) These occur between the membranes and the brain, as
a result of hemorrhage or of softening. Porencephalus is a sequel of con-
genital atrophy or of haemorrhage, or may be due to a developmental defect.
Hydatid cysts have been referred to in the section on parasites. An interest-
ing variety of cyst is that which follows severe injury to the skull in early life.
Symptoms. — (1) General. — The following are the most important:
Headache, either dull, aching, and continuous, or sharp, stabbing, and par-
oxysmal. It may be diffused over the entire head; sometimes it is limited
to the back or front. When in the back of the head it may extend down the
neck (especially in tumors in the posterior fossa), and when in the front it
may be accompanied with neuralgic pains in the face. Occasionally the pain
may be very localized and associated with tenderness on pressure.
Optic neuritis occurs in four-fifths of all the eases (Gowers). It should
be looked for in every patient presenting cerebral symptoms, for it may be
present in high degree without impairment of vision. Loss of visual acuity
usually indicates that optic atrophy has set in. It is usually double, but occa-
sionally is found in only one eye. A growth may develop slowly and attain
considerable size without producing optic neuritis. On the other hand, it may
occur with a very small tumor. J. A. Martin, from an extensive analysis of the
literature with reference to the localizing value, concludes : When there is a
difference in the amount of the neuritis in each eye it is more than twice as
probable that the tumor is on the side of the most marked neuritis. It is con-
stant in tumors of the corpora quadrigemina, present in 89 per cent of cere-
bellar tumors, and absent in nearly two-thirds of the cases of tumor of the
pons, medulla, and of the corpus callosum. It is least frequent in cases of
tuberculous tumor; most common in cases of glioma and cystic tumors.
Vomiting is a common feature, and with headache and optic neuritis
makes up the characteristic clinical picture of cerebral tumor. An important
point is the absence of definite relation to the meals. A chemical examination
shows that the vomiting is independent of digestive disturbances. It may
be very obstinate, particularly in growths of the cerebellum and the pons.
Giddiness is often an early symptom. The patient complains of vertigo
on rising suddenly or on turning quickly. Mental Disturbance. — The patient
may act in an odd, unnatural manner, or there may be stupor and heaviness.
The patient may become emotional or silly, or symptoms resembling hysteria
may develop. Convulsions, either general and resembling true epilepsy or
localized ( Jacksonian) in character. There may be slowing of the pulse, as in
all cases of increased intracranial pressure.
(2) Localizing Symptoms. — Focal symptoms often occur, but it must
not be forgotten that these may be indirectly produced. The smaller the
tumor and the less marked the general symptoms of cerebral compression, the
more likely is it that any focal symptoms occurring are of direct origin.
(a) Central Motor Area. — The symptoms are either irritative or destruc-
tive in character. Irritation in the lower third may produce spasm in the
muscles of the face, in the angle of the mouth, or in the tongue. The spasm
990 DISEASES OF THE NERVOUS SYSTEM.
with tingling may be strictl}' limited to one muscle group before extending to
others, and this Seguin terms the signal symptom. The middle third of the
motor area contains the centres controlling the arm, and here, too, the spasm
may begin in the fingers, in the thumb, in the muscles of the wrist, or in the
shoulder. In the upper third of the motor areas the irritation may produce
spasm beginning in the toes, in the ankles, or in the muscles of the leg. In
many instances the patient can determine accurately the point of origin of
the spasm, and there are imjiortant sensory disturbances, such as numbness
and tingling, which may be felt first at the region affected.
In all cases it is important to determine, first, the point of origin, the
signal symptom; second, the order or march of the spasm; and third, the
subsequent condition of the parts first affected, whether it is a state of paresis
or angesthesia.
Destructive lesions in the motor zone cause paralysis, which is often pre-
ceded by local convulsive seizures; there may be a monoplegia, as of the leg,
and convulsive seizures in the arm, often due to irritation in these centres.
Tumors in the neighborhood of the motor area may cause localized spasms and
subsequently, as the centres are invaded by the growth, paralysis occurs. On
the left side, growths in the third frontal or Broca's convolution may cause
motor aphasia.
(&) Prefrontal Begion. — Xeither motor nor sensory disturbance may be
present. The general sjanptoms are often well marked. The most striking
feature of growths in this region is mental torpor and gradual imbecility.
Particularly when the left side is involved mental characteristics may be
greatly altered. In its extension downward the tumor may involve on the left
side the lower frontal convolution and produce aphasia, or in its progress
backward cause irritative or destructive lesions of the motor area. Exophthal-
mos on the side of the tumor may occur and be helpful in diagnosis, as in the
case reported by Thomas and Keene.
(c) Tumors in the parieto-occipital lohe may grow to a large size without
causing any symptoms. There may be word-blindness and mind-blindness
when the angular g}Tus and its underlying white matter is involved, and
paraphasia. Astereognosis may accompany growths in the superior parietal
region.
(d) Tumors of the occipital lohe produce hemianopsia, and a bilateral lesion
may produce blindness. Tumors in this region on the left hemisphere may
be associated with word-blindness and mind-blindness.
(e) Tumors in the temporal lohe may attain a large size without produc-
ing s}Tnptoms. In their growth they involve the lower motor centres. On
the left side involvement of the first g}Tus and the transverse temporal gyri
(auditory sense area) may be associated with word-deafness.
(/) Tumors growing in the neighborhood of the hasal ganglia produce
hemiplegia from involvement of the internal capsule. Limited growths in
either the nucleus caudatus or the nucleus lentiformis of the corpus striatum
do not necessarily cause paralysis. Tumors in the thalamus opticus may
also, when small, cause no symptoms, but increasing they may involve the
fibres of the sensor}^ portion of the internal capsule, producing hemianopsia
and sometimes hemiansesthesia. Growths in this situation are apt to cause
early optic neuritis, and, growing into the third ventricle, may cause a dis-
DIFFUSE AND FOCAL DISEASES OF THE BRAIN. 991
tention of the lateral ventricles. In fact, pressure symptoms from this cause
and paralysis due to involvement of the internal capsule are the chief symp-
toms of tumor in and about these ganglia. If the ventrolateral group of
nuclei in the thalamus be involved there may be unilateral disturbances of
cutaneous and muscular sense, hemichorea, or movement ataxia.
G-rowths in the corpora quadrigemina are rarely limited, but most com-
monly involve the crura cerebri as well. Ocular symptoms are marked. The
pupil reflex is lost and there is nystagmus. In the gradual grovi^th the third
nerve is involved as it passes through the crus, in which case there will be
oculo-motor paralysis on one side and hemiplegia on the other, a combination
almost characteristic of unilateral disease of the crus.
(g) Tumors of the pons and medulla. The symptoms are chiefly those
of pressure upon the nerves emerging in this region. In disease of the pons
the nerves may be involved alone or with the pyramidal tract. Of 53 cases
analyzed by Mary Putnam Jacobi, there were 13 in which the cerebral nerves
were involved alone, 13 in which the limbs were affected, and 26 in which
there was hemiplegia and involvement of the nerves. Twenty-two of the latter
had what is known as alternate paralysis — i. e., involvement of the nerves on
one side and of the limbs on the opposite side. In 4 cases there were no motor
symptoms. In tuberculosis (or syphilis) a growth at the inferior and inner
aspects of the crus may cause paralysis of the third nerve on one side, and of
the face, tongue, and limbs on the opposite side (syndrome of Weber). A
tumor growing in the lower part of the pons usually involves the sixth nerve,
producing internal strabismus, the seventh nerve, producing facial paralysis,
and the auditory nerve, causing deafness. Conjugate deviation of the eyes
to the side opposite that on which there is facial paralysis also occurs. When
the motor cerebral nerves are involved the paralyses are of the peripheral
type (lower segment paralyses).
Tumors of the medulla may involve the cerebral nerves alone or cause
in some instances a combination of hemiplegia with paralysis of the nerves.
Paralyses of the nerves are helpful in topical diagnosis, but the fact must not
be overlooked that one or more of the cerebral nerves may be paralyzed as
a result of a much increased general intracranial pressure. Signs of irritation
in the ninth, tenth, and eleventh nerves are usually present, and produce
difficulty in swallowing, irregular action of the heart, irregular respiration,
vomiting, and sometimes retraction of the head and neck. The hypoglossal
nerve is least often affected. The gait may be unsteady or, if there is pressure
on the cerebellum, ataxic. Occasionally there are sensory symptoms, numbness,
and tingling. Toward the end convulsions may occur.
Tumors of the pituitary body are not uncommon, and are usually of the
nature of fibroma or myxoma. They may accompany acromegaly. Landois
and Roy have reported 16 cases.
Diagnosis. — From the general symptoms alone the existence of tumor may
be determined, for the combination of headache, optic neuritis, and vomiting
is distinctive. A gradual increase in the intensity of the symptoms is usually
seen. It must not be forgotten that severe headache and neuro-retinitis may
be caused by Bright's disease. The localization must be gathered from the
consideration of the symptoms above detailed and from the data given in the
section on Topical Diagnosis of Diseases of the Brain. Mistakes are most
992 DISEASES OF THE NERVOUS SYSTEM.
likely to occur in connection with uraemia, hysteria, and general paralysis;
but careful consideration of all the circumstances of the case usually enables
the practitioner to avoid error. Auscultatory percussion is occasionally of
service in localization.
Prognosis. — Syphilitic tumors alone are amenable to medical treatment.
Tuberculous growths occasionally cease to grow and become calcified. The
gliomata and fibromata, particularly when the latter grow from the membranes,
may last for 3'ears. I have described a case of small, hard glioma, in which
the Jacksonian epilepsy persisted for fourteen years. Hughlings Jackson has
reported cases of glioma in which the symptoms lasted for over ten years. The
more rapidly growing sarcomata usually prove fatal in from six to eighteen
months. Death may be sudden, particularly in growths near the medulla;
more commonly it is due to coma in consequence of gradual increase in the
intracranial pressure.
Treatment. — (a) Medical. — If there is a suspicion of syphilis the iodide
of potassium and mercury should be given. Xowhere do we see more brilliant
therapeutical efilects than in certain cases of cerebral gummata. The iodide
should be given in increasing doses. In tuberculous tumors the outlook is less
favorable, though instances of cure are reported, and there is post-mortem
evidence to show that the solitary tuberculous tumors may undergo changes
and become obsolete. A general tonic treatment is indicated in these cases.
The headache usually demands prompt treatment. The iodide of potassium
in full doses sometimes gives marked relief. An ice-cap for the head or, in
the occipital headache, the application of the Paquelin cautery may be tried.
The bromides are not of much use in the headache from this cause, and, as
the last resort, morphia must be given. For the convulsions bromide of
potassium is of little service.
(&) Surgical. — Tumors of the brain have been successfully removed by
Macewen, Horsley, Keen, and others. The percentage of cases in which extir-
pation is possible, however, is small. Of 1,277 cases collected by Starr, only
104 were removable. The most advantageous cases are the localized fibromata
and sarcomata growing from the dura and only compressing the brain sub-
stance, as in Keen's remarkable case. Of late years there have been numerous
successful operations with removal of growths from the cerebellum and cere-
bello-pontine recess. The safety with which the exploratory operation can be
made warrants it in all doubtful cases. Even if the tumor be inaccessible, a
palliative craniectomy may be indicated, for by relieving the intracranial ten-
sion it may suffice to check the headache, vomiting, and optic neuritis.
V. INFLAMMATION OF THE BRAIN.
1. x4.cuTE Encephalitis.
A focal or diffuse inflammation of the brain substance, usually of the gray
■ matter (poliencephalitis), is met with (a) as a result of trauma; (&) in cer-
tain intoxications, alcohol, food poisoning, and gas poisoning; and (c) follow-
ing the acute infections. The anatomical features are those of an acute
hemorrhagic poliencephalitis, corresponding in histological details with acute
polio-myelitis. Focal forms are seen in ulcerative endocarditis, in which the
DIFFUSE AND FOCAL DISEASES OF THE BRAIN. 993
gray matter may present deeply haemorrliagic areas, firmer than the surround-
ing tissue. In the fevers there may be more extensive regions, involving two
or three convolutions. This acute hsemorrhagic poliencephalitis superior is
thought by Striimpell to be the essential lesion in infantile hemiplegia. Local-
izing symptoms are usually present, though they may be obscured in the
severity of the general infection. The most typical encephalitis accompanies
the meningitis in cerebro-spinal fever.
In acute mania, in delirium tremens, in chorea insaniens, in the maniacal
form of exophthalmic goitre, and in the so-called cerebral forms of the malig-
nant fevers the gray cortex is deeply congested, moist, and swollen, and with
the recent finer methods of research will probably show changes which may
be classed as encephalitis.
The symptoms are not very definite. In severe forms they are those of
an acute infection; some cases have been mistaken for typhoid fever. The
onset may be abrupt in an individual apparently healthy. Other cases have
occurred in the convalescence from the fevers, particularly influenza. One of
J. J. Putnam's cases followed mumps. The general symptoms are those which
accompany all severe acute affections of the brain — headache, somnolence,
coma, delirium, vomiting, etc. The local symptoms are very varied, depend-
ing on the extent of the lesions, and may be irritative or paralytic. Usually
fatal within a few weeks, cases may drag on for weeks or months and recover.
2. Abscess of the Braust,
Etiology. — Suppuration of the brain substance is rarely if ever primary,
but results, as a rule, from extension of inflammation from neighboring parts
or infection from a distance through the blood. The question of idiopathic
brain abscess need scarcely be considered, though occasionally instances occur
in which it is extremely difiicult to assign a cause. There are three important
etiological factors:
(1) Trauma. Falls upon the head or blows, with or without abrasion of
the skin. More commonly it follows fracture or punctured wounds. In this
group meningitis is frequently associated with the abscess.
(2) By far the most important infective foci are those which arise in
direct. extension from disease of the middle ear, of the mastoid cells, or of the
frontal sinuses. From the roof of the mastoid antrum the infection readily
passes to the sigmoid sinus and induces an infective thrombosis. In other
instances the dura becomes involved, and a subdural abscess is formed, which
may readily involve the arachnoid or the pia mater. In another group the
inflammation extends along the lymph spaces, or the thrombosed veins, into
the substance of the brain and causes suppuration. Macewen thinks that with-
out local areas of meningitis the infective agents may be carried through the
lymph and blood channels into the cerebral substance. Infection which ex-
tends from the roof of the tympanic cavity is most likely to be followed by
abscess in the temporal lobe, while infection extending from the mastoid cells'
causes most frequently sinus thrombosis and cerebellar abscess.
(3) In septic processes. Abscess of the brain is not often found in pyae-
mia. In ulcerative endocarditis multiple foci of suppuration are common.
Localized bone-disease and suppuration in the liver are occasional causes. Cer-
994 DISEASES OF THE NERVOUS SYSTEM.
tain inflammations in the lungs, particularly bronchiectasis, which was present
in 17 of 38 cases of these so-called "pulmonal cerebral abscesses" collected
by E. T. Williamson, are liable to be followed by abscess. It is an occasional
complication of empyema. Abscess of the brain may follow the specific fevers.
Bristowe has called attention to its occurrence as a sequel of influenza. The
largest number of cases occur between the twentieth and fortieth years, and
the condition is more frequent in men than in women. Holt has collected 25
cases in children under five 3'ears of age, the chief causes of which were otitis
media and trauma.
Morbid Anatomy. — The abscess may be solitary or multiple, diffuse or cir-
cumscribed. Practically any one of the different varieties of pyogenic bac-
teria may be concerned. The bacteriological examination often shows a mix-
ture of different varieties. Occasionally cultures are sterile, owing to death
of the bacteria. In the acute, rapidly fatal cases following injury the suppura-
tion is not limited; but in long-standing cases the abscess is enclosed in a
definite capsule, which may have a thickness of from 2 to 5 mm. The pus
varies much in appearance, depending upon the age of the abscess. In early
eases it may be mixed with reddish debris and softened brain matter, but in
the solitary encapsulated abscess the pus is distinctive, having a greenish tint,
an acid reaction, and a peculiar odor, sometimes like that of sulphuretted
hydrogen. The brain substance surrounding the abscess is usually oedematous
and infiltrated. The size varies from that of a walnut to that of a large orange.
There are cases on record in which the cavity has occupied the greater portion
of a hemisphere. Multiple abscesses are usually small. In four-fifths of all
eases the abscess is solitary. Suppuration occurs most frequently in the cere-
brum, and the temporal lobe is more often involved than other parts. The
cerebellum is the next most common seat, particularly in connection with ear-
disease.
Symptoms. — Following injury or operation the disease may run an acute
course, with fever, headache, delirium, vomiting, and rigors. The s}TQptoms
are those of an acute meningo-encephalitis, and it may be very difficult to
determine, unless there are localizing s}Tnptoms, whether there is really sup-
puration in the brain substance. In the cases following ear-disease the symp-
toms may at first be those of meningeal irritation. There may be irritability,
restlessness, severe headache, and aggravated earache. Other striking symp-
toms, particularly in the more prolonged cases, are drowsiness, slow cerebration,
vomiting, and optic neuritis. In the chronic form of brain abscess which may
follow injury, otorrhcea, or local limg trouble, there may be a latent period
ranging from one or two weeks to several months, or even a year or more.
In the " silent " regions, when the abscess becomes encapsulated there ma}^ be
no s}Tnptoms whatever during the latent period. During all this time the
patient may be under careful observation and no suspicion be aroused of the
existence of suppuration. Then severe headache, vomiting, and fever set in,
perhaps with a chill. So, too, after a blow upon the head or a fracture the
symptoms of the lesion may be transient, and months afterward cerebral sjmip-
toms of the most aggravated character may develop.
The localization of the lesion is often difficult. If situated in or near
the motor region there may be convulsions or paralysis, and it is to be remem-
bered that an abscess in the temporal lobe may compress the lower part of the
DIFFUSE AND FOCAL DISEASES OF THE BRAIN. 995
pre-central convolution and produce paralysis of the arm and face, and on the
left side cause aphasia. A large abscess may exist in the frontal lobe without
causing paralysis, but in these cases there is almost always some mental dul-
ness. In the temporal lobe, the common seat, there may be no focalizing
symptoms. So also in the parieto-occipital region; though here early exam-
ination may lead to the detection of hemianopia. In abscess of the cerebellum
vomiting is common. If the middle lobe is affected there may be staggering
— cerebellar incoordination. Localizing symptoms in the pons and other parts
are still more uncertain.
Diagnosis. — In the acute cases there is rarely any doubt. A consideration
of possible etiological factors is of the highest importance. The history of
injury followed by fever, marked cerebral symptoms, the development of
rigors, delirium, and perhaps paralysis, make the diagnosis certain. In chronic
ear-disease, such cerebral symptoms as drowsiness and torpor, with irregular
fever, supervening upon the cessation of a discharge, should excite the suspicion
of abscess. Cases in which suppurative processes exist in the orbit, nose, or
naso-pharynx, or in which there has been subcutaneous phlegmon of the head
or neck, a parotitis, a facial erysipelas, or tuberculous or syphilitic disease
of the bones of the skull, should be carefully watched, and immediately in-
vestigated should cerebral symptoms appear. It is particularly in the chronic
cases that difficulties arise. The symptoms resemble those of tumor of the
brain; indeed, they are those of tumor plus fever. Choked disk, however, so
commonly associated with tumor, is very frequently absent in abscess of the
brain. In a patient with a history of trauma or with localized lung or pleural
trouble, who for weeks or months has had slight headache or dizziness, the onset
of a rapid fever, especially if it be intermittent and associated with rigors,
intense headache, and vomiting, points strongly to abscess. The pulse-rate in
cases of cerebral abscess is usually accelerated, but cases are not rare in which
it is slowed. Macewen lays stress upon the value of percussion of the skull
as an aid in diagnosis. The note, which is uniformly dull, becomes much more
resonant when the lateral ventricles are distended in cerebellar abscess and
in conditions in which the venge Galeni are compressed.
It is not always easy to determine whether the meninges are involved with
the abscess. Often in ear-disease the condition is that of meningo-encephalitis.
Sometimes in association with acute ear-disease the symptoms may simulate
closely cerebral meningitis or even abscess. Indeed, Cowers states that not
only may these general symptoms be produced by ear-disease, but even distinct
optic neuritis.
Treatment. — A remarkable advance has been made of late years in dealing
with these cases, owing to the impunity with which the brain can be explored.
In ear-disease free discharge of the inflammatory products should be promoted
and careful disinfection practised. The treatment of injuries and fractures
comes within the scope of the surgeon. The acute symptoms, such as fever,
headache, and delirium, must be treated by rest, an ice-cap, and, if necessary,
local depletion. In all cases, when a reasonable suspicion exists of the occur-
rence of abscess, the trephine should be used and the brain explored. The cases
following ear-disease, in which the suppuration is in the temporal lobe or in
the cerebellum, offer the most favorable chances of recovery. The localization
can rarely be made accurately in these cases, and the operator must be guided
996 DISEASES OF THE NERVOUS SYSTEM.
more by general anatomical and pathological knowledge. In cases of injury
the trephine should be applied over the seat of the blow or the fracture. In
ear-disease the suppuration is most frequent in the temporal lobe or in the
cerebellum, and the operation should be performed at the points most accessible
to these regions. And, lastly, a most important, one might almost say essen-
tial, factor in the successful treatment of intracranial suppuration is an
intelligent knowledge on the part of the surgeon of the work and works of
Sir William Macewen.
VI. HYDROCEPHALUS.
Definition. — A condition, congenital or acquired, in which there is a great
accumulation of fluid within the ventricles of the brain.
The term hydrocephalus has also been applied to the collection of fluid
between the cortex of the brain and the skull, known in this situation as
hydrocephalus externus or hydroceplialus ex vacuo, a condition common in
cases of atrophy of the brain substance, met with in old age, after hsemorrhages,
softenings, or scleroses, in lingering and cachectic diseases, as cancer, chronic
nephritis, chronic alcoholism, and sometimes in rickets. Occasionally the dis-
ease is caused by meningeal cysts. A true drops}^, however, of the araclinoid
sac probably does not occur.
The cases may be divided into three groups — idiopathic internal hydro-
cephalus (serous meningitis), congenital or infantile, and secondary or ac-
quired.
(1) Serous Meningitis (Quincke) (Idiopathic Internal Hydrocephalus;
Angio-neurotic Hydrocephalus) . — This remarkable form, described by Quincke,
is very important, since a knowledge of the condition may explain very anom-
alous and puzzling cases. It is an ependymitis causing a serous effusion into
the ventricles, with distention and pressure effects. It may be compared to the
serous exudates in the pleura or in sjmovial membranes. It is not certain
that the process is inflammatory, and Quincke likens it to the angio-neurotic
cedema of the skin. In very acute cases the ependyma may be smooth and
natural looking; in more chronic cases it may be thickened and sodden. The
exudate does not differ from the normal, and if on lumbar puncture a fluid is
removed of a specific gravity above 1.009, with albumin above two tenths per
cent, the condition is more likel}^ to be hydrocephalus from stasis, secondary
to tumor, etc.
Both children and adults are affected, the latter more frequently. In the
acute form the condition is mistaken for tuberculous or purulent meningitis.
There are headache, retraction of the neck, and signs of increased intracranial
pressure, choked disks, slow pulse, etc. Fever is usually absent, but I have
seen one case with recurring paroxysms of fever, and Morton Prince has
described a similar one. In both the exudate was clear and the ependyma not
acutely inflamed. Quincke has reported cases of recovery. In the chronic
form the symptoms are those of tumor — general, such as headache, slight fever,
somnolence, and delirium; and local, as exophthalmos, optic neuritis, spasms,
and rigidity of muscles and paralysis of the cerebral nerves. Eemarkable ex-
acerbations occur, and the symptoms vary in intensity from day to day.
Eecovery may follow after an illness of many weeks, and some of the re-
DIFFUSE AND FOCAL DISEASES OF THE BRAIN. 997
ported cases of disappearance of all symptoms of brain tumor belong in this
category.
(3) Congenital Hydrocephalus. — The enlarged head may obstruct labor;
more frequently the condition is noticed some time after birth. The cause
is unknown. It has occurred in several members of the same family.
The anatomical condition in these cases offers no clew to the nature of
the trouble. The lateral ventricles are enormously distended, but the ependyma
is usually clear, sometimes a little thickened and granular, and the veins large.
The choroid plexuses are vascular, sometimes sclerotic, but often natural look-
ing. The third ventricle is enlarged, the aqueduct of Sylvius dilated, and the
fourth ventricle may be distended. The quantity of fluid may reach several
litres. It is limpid and contains a trace of albumin and salts. The changes
in consequence of this enormous ventricular distention are remarkable. The
cerebral cortex is greatly stretched, and over the middle region the thickness
may amount to no more than a few millimetres without a trace of the sulci
or convolutions. The basal ganglia are flattened. The skull enlarges, and the
circumference of the head of a child of three or four years may reach 25 or
even 30 inches. The sutures widen. Wormian bones develop in them, and the
bones of the cranium become exceedingly thin. The veins are marked beneath
the skin. A fluctuation wave may sometimes be obtained, and Fisher's brain
murmur may be heard. The orbital plates of the frontal bone are depressed,
causing exophthalmos, so that the eyeballs can not be covered by the eyelids.
The small size of the face, widening somewhat above, is striking in comparison
with the enormously expanded skull.
Convulsions may occur. The reflexes are increased, the child learns to
walk late, and ultimately in severe cases the legs become feeble and sometimes
spastic. Sensation is much less affected than motility. Choked disk is not
uncommon. The mental condition is variable; the child may be bright, but,
as a rule, there is some grade of imbecility. The congenital cases usually die
within the first four or five years. The process may be arrested and the patient
may reach adult life. Cases of this sort are not very uncommon. Even when
extreme, the mental faculties may be retained, as in Bright's celebrated patient.
Cardinal, who lived to the age of twenty-nine, and whose head was translucent
when the sun. was shining behind him. Care must be taken not to mistake
the rachitic head for hydrocephalus.
(3) Acquired Chronic Hydrocephalus. — This is stated to be occasionally
primary (idiopathic) — that is to say, it comes on spontaneously in the adult
without observable lesion. Dean Swift is said to have died of hydrocephalus,
but this seems very unlikely. It is based upon the statement that "he (Mr.
White way) opened the skull and found much water in the brain," a condition
no doubt of hydrocephalus ex vacuo, due to the wasting associated with his pro-
longed illness and paralysis. In nearly all cases there is either a tumor at the
base of the brain or in the third ventricle, which compresses the venae Galeni.
The passage from the third to the fourth ventricle may be closed, either by a
tumor or by parasites. More rarely the foramen of Magendie, through which
the ventricles communicate with the cerebro-spinal meninges, becomes closed by
meningitis. Chronic inflammations of the ependyma may in similar fashion
block the foramina of exit of the ventricular fluid. There may be imilateral
hydrocephalus from closure of one of the foramina of Monro. These condi-
998 DISEASES OF THE NERVOUS SYSTEM.
tions^ occurring in adults, may produce the most extreme hydrocephalus with-
out any enlargement of the head. Even when the tumor begins early in life
there may be no expansion of the skull. In the case of a girl aged sixteen,
blind from her third year, the head was not unusually large, the ventricles were
enormously distended, and in the Eolandic region the brain substance was only
5 mm. in thickness. A tumor occupied the third ventricle. In a case of
cholesteatoma of the floor of the third ventricle, in which the symptoms per-
sisted at intervals for eight or nine years, the ventricles were enormously
distended without enlargement of the skull. In other instances the sutures
separate and the head gradually enlarges.
The symptoms of hydrocephalus in the adult are curiously variable. In
the first case mentioned there were early headaches and gradual blindness;
then a prolonged period in which she was able to attend to her studies. Head-
aches again supervened, the gait became irregular and somewhat ataxic. Death
occurred suddenly. In the other case there were prolonged attacks of coma
with a slow pulse, and on one occasion the patient remained unconscious for
more than three months. Gradually progressing optic neuritis without focal-
izing symptoms, headache, and attacks of somnolence or coma are suggestive
symptoms. These cases of acquired chronic hydrocephalus can not be certainly
diagnosed during life, though in certain instances the condition may be sus-
pected. They simulate tumor very closely.
Treatment. — Very little can be done to relieve hydrocephalus. Medicines
are powerless to cause the absorption of the fluid. More rational is the system
of gradual compression, with or without the withdrawal of small quantities of
the fluid. The compression may be made by means of broad plasters, so applied
as to cross each other on the vertex, and another may be placed round the cir-
cumference. In the meningitis serosa Quincke advises the use of mercury.
Of late years puncture of the ventricles, an operation which had been
abandoned, has been revived; it has been resorted to in the meningitis serosa.
When pressure s^^mptoms are marked Quincke's procedure may be used. He
recommends puncture of the subarachnoid sac between the third and the fourth
lumbar vertebrge. At this point the spinal cord can not be touched. The
advantages are a slower removal of fluid and less danger of collapse.
Attempts have been made recently to find some method of establishing per-
manent drainage, either between the ventricles and the intracranial subdural
space or between the lumbar subaraclmoid space and the abdominal cavity.
F. DISEASES OF THE PERLPHEKAL KERVES.
I. NEURITIS (Inflammation of the Bundles of Nerve Fibres).
Xeuritis may be localized in a single nerve, or general, involving a large
number of nerves, in which case it is usually known as 7niiltiph neuritis or
polynetiritis.
Etiology. — Localized neuritis arises from (a) cold, which is a very fre-
quent cause, as, for example, in the facial nerve. This is sometimes known
as rheumatic neuritis. (&) Traumatism — wounds, blows, direct pressure on
the nerves, the tearing and stretching which follow a dislocation or a frac-
DISEASES OF THE PERIPHERAL NERVES. 999
tiire, and the hypodermic injection of ether. Under this section come also
the professional palsies, due to pressure in the exercise of certain occupations,
(c) Extension of inflammation from neighboring parts, as in a neuritis of the
facial nerve due to caries in the temporal bone, or in that met with in syphilitic
disease of the bones, disease of the joints, and occasionally in tumors.
Multiple neuritis has a very complex etiology, the causes of which may
be classified as follows: (a) The poisons of infectious diseases, as in leprosy,
diphtheria, typhoid fever, small-pox, scarlet fever, and occasionally in other
forms; (h) the organic poisons, comprising the diffusible stimulants, such
as alcohol and ether, bisulphide of carbon and naphtha, and the metallic
bodies, such as lead, arsenic, and mercury; (c) cachectic conditions, such as
occur in angemia, cancer, tuberculosis, or marasmus from any cause; (d) the
endemic neuritis or beri-beri; and (e) lastly, there are cases in which none
of these factors prevail, but the disease sets in suddenly after overexertion or
exposure to cold.
Morbid Anatomy. — In neuritis due to the extension of inflammation the
nerve is usually swollen, infiltrated, and red in color. The inflammation may
be chiefly perineural or it may pass into the deeper portion — interstitial neu-
ritis— in which form there is an accumulation of lymphoid elements between
the nerve bundles. The nerve fibres themselves may not appear involved, but
there is an increase in the nuclei of the sheath of Schwann. The myelin is
fragmented, the nuclei of the internodal cells are swollen, and the axis-cylin-
ders present varicosities or undergo granular degeneration. Ultimately the
nerve fibres may be completely destroyed and replaced by a fibrous connective
tissue in which much fat is sometimes deposited — the lipomatous neuritis of
Ley den.
In other instances the condition is termed parenchymatous neuritis, in
which the changes are like those met with in the secondary or Wallerian
degeneration, which follows when the nerve fibre is cut off from the cell body
of the neurone to which it belongs. The medullary substance and the axis-
cylinders are chiefly involved, the interstitial tissue being but little altered or
only affected secondarily. The myelin becomes segmented and divides into
small globules and granules, and the axis-cylinders become granular, broken,
subdivided, and ultimately disappear. The nuclei of the sheath of Schwann
proliferate and ultimately the fibres are reduced to a state of atrophic tubes
without a trace of the normal structure. The muscles connected with the
degenerated nerves usually show marked atrophic changes, and in some
instances the change in the nerve sheath appears to extend directly to the
interstitial tissue of the muscles — the neuritis fascians of Eichhorst.
Symptoms. — (a) Localized Neuritis. — As a rule the constitutional dis-
turbances are slight. The most important symptom is pain of a boring or
stabbing character, usually felt in the course of the nerve and in the parts to
which it is distributed. The nerve itself is sensitive to pressure, probably, as
Weir Mitchell suggests, owing to the irritation of its nervi nervorum. The
skin may be slightly reddened or even oedematous over the seat of the inflam-
mation. Mitchell has described increase in the temperature and sweating
in the affected region, and such trophic disturbances as effusion into the Joints
and herpes. The function of the muscle to which the nerve fibres are distrib-
uted is impaired, motion is painful, and there may be twitchings or contrac-
1000 DISEASES OF THE NERVOUS SYSTEM.
tions. The tactile sensation of the part may be somewhat deadened, even when
the pain is greatly increased. In the more chronic cases of local neuritis, such,
for instance, as follow the dislocation of the humerus, the localized pain, which
at first may be severe, gradually disappears, though some sensitiveness of the
brachial plexus may persist for a long time, and the nerve cords may be felt
to be swollen and firm. The pain is variable — sometimes intense and distress-
ing; at others not causing much inconvenience. Xumbness and formication
may be present and the tactile sensation may be greatly impaired. The motor
disturbances are marked. Ultimately there is extreme atrophy of the muscles.
Contractures may occur in the fingers. The skin may be reddened or glossy,
the subcutaneous tissue cedematous, and the nutrition of the nails may be
defective. In the rheumatic neuritis subcutanous fibroid nodules may develop.
A neuritis limited at first to a peripheral nerve may extend upward —
the so-called ascending or migratory neuritis — and involve the- larger nerve
trunks, or even reach the spinal cord, causing subacute myelitis (Gowers).
The condition is rarely seen in the neuritis from cold, or in that which fol-
lows fevers; but it occurs most frequently in traumatic neuritis.
J. K. Mitchell, in his monograph on injuries of nerves, concludes that the
larger nerve trunks are most susceptible, and that the neuritis may spread either
up or down, the former being the most common. The paralysis secondary to
visceral disease, as of the bladder, may be due to an ascending neuritis. The
inflammation may extend to the nerves of the other side, either through the
spinal cord or its membranes, or Avithout any involvement of the nerve-cen-
tres, the so-called sympathetic neuritis. The electrical changes in localized
neuritis vary a great deal, depending upon the extent to which the nerve is
injured. The lesion may be so slight that the nerve and the muscles to which it
is distributed may react normally to both currents ; or it may be so severe that
the t}^ical reaction of degeneration develops within a few days — i. e., the nerve
does not respond to stimulation by either current, while the muscle reacts only
to the galvanic current and in a peculiar maimer. The contraction caused is
slow and lazy, instead of sharp and quick as in the normal muscle, and the
AC contraction is usually stronger than the KC contraction. Between these
two extremes there are many different grades, and a careful electrical exam-
ination is most important as an aid to diagnosis and prognosis.*
The duration varies from a few days to weeks or months. A slight trau-
matic neuritis may pass off in a day or two, while the severer cases, such as
follow unreduced dislocation of the humerus, may persist for months or never
be completely relieved.
(6) Multiple Neuritis. — This presents a complex sjTQptomatology. The
following are the most important groups of cases :
(1) Acute Fehrile Polyneuritis. — The attack follows exposure to cold or
overexertion, or, in some instances, comes on spontaneously. The onset resem-
bles that of an acute infectious disease. There may be a definite chill, pains
in the back and limbs or joints, so that the case may be thought to be acute
rheumatism. The temperature rises rapidly and may reach 103° or 104°.
There are headache, loss of appetite, and the general symptoms of acute in-
fection. The limbs and back ache. Intense pain in the nerves, however, is
* See under Facial Paralysis.
DISEASES OF THE PERIPHERAL NERVES. 1001
by no means constant. Tingling and formication are felt in the fingers and
toes, and there is increased sensitiveness of the nerve trunks or of the entire
limb. Loss of muscular power, first marked, perhaps, in the legs, gradually
comes on and extends with the features of an ascending paralysis. In other
cases the paralysis begins in the arms. The extensors of the wrists and the
flexors of the ankles are early affected, so that there is foot and wrist drop.
In severe cases there is general loss of muscular power, producing a flabby
paralysis, which may extend to the muscles of the face and to the intercostals,
and respiration may be carried on by the diaphragm alone. The muscles soften
and waste rapidly. There may be only hypersesthesia with soreness and stiff-
ness of the limbs; in some cases, increased sensitiveness with anaesthesia; in
other instances the sensory disturbances are slight. The clinical picture is
not to be distinguished, in many cases, from Landry's paralysis ; in others, from
the subacute myelitis of Duchenne.
The course is variable. In the most intense forms the patient may die in
a week or ten days, with involvement of the respiratory muscles or from
paralysis of the heart. As a rule in cases of moderate severity, after persist-
ing for five or six weeks, the condition remains stationary and then slow
improvement begins. The paralysis in some muscles may persist for many
months and contractures may occur from shortening of the muscles, but even
when this occurs the outlook is, as a rule, good, . although the paralysis may
have lasted for a year or more.
(3) Recurring Multiple Neuritis. — Under the term polyneuritis recurrens
Mary Sherwood has described from Eichhorst's clinic 2 cases in adults — in
one case involving the nerves of the right arm, in the other both legs. In
one patient there were three attacks, in the other two, the distribution in the
various attacks being identical. The subject has been fully discussed by H. M.
Thomas (Phila. Med. Jour., 1898, i).
(3) Alcoholic Neuritis. — This, perhaps the most important form of mul-
tiple neuritis, was graphically described in 1832 by James Jackson, Sr., of
Boston. Wilks recognized it as alcoholic paraplegia, but the starting-point
of the recent researches on the disease dates from the observations of Dumenil,
of Eouen. Of late years our knowledge of the disease has extended rapidly,
owing to the researches of Huss, Leyden, James Boss, Buzzard, and Henry
Hun. It occurs most frequently in women, particularly in steady, quiet tip-
plers. Its appearance may be the first revelation to the physician or to the
family of habits of secret drinking. The onset is usually gradual, and may
be preceded for weeks or months by neuralgic pains and tingling in the feet
and hands. Convulsions are not uncommon. Fever is rare. The paralysis
gradually sets in, at first in the feet and legs, and then in the hands and fore-
arms. The extensors are affected more than the flexors, so that there is wrist-
drop and foot-drop. The paralysis may be thus limited and not extend higher
in the limbs. In other instances there is paraplegia alone, while in the most
extreme cases all the extremities are involved. In rare instances the facial
muscles and the sphincters are also affected. The sensory symptoms are very
variable. There are cases in which there are numbness and tingling only,
without great pain. In other cases there are severe burning or boring pains,
the nerve trunks are sensitive, and the muscles are sore when, grasped. The
hands and feet are frequently swollen and congested, particularly when held
1002 DISEASES OF THE NERVOUS SYSTEM.
down for a few moments. The cutaneous reflexes as a rule are preserved.
The deep reflexes are usually lost.
The course of these alcoholic cases is, as a rule, favorable, and after per-
sisting for weeks or months improvement gradually begins, the muscles regain
their power, and even in the most desperate cases recovery may follow. The
extensors of the feet may remain paralyzed for some time, and give to the
patient a distinctive walk, the so-called steppage gait, characteristic of periph-
eral neuritis. It is sometimes known as the pseudo-tabetic gait, although in
reality it could not well be mistaken for the gait of ataxia. The foot is thrown
forcibly forward, the toe lifted high in the air so as not to trip upon it. The
entire foot is slapped upon the ground as a flail. It is an awkward, clumsy
gait, and gives the patient the appearance of constantly stepping over obstacles.
Among the most striking features of alcoholic neuritis are the mental symp-
toms. Delirium is common, and there may be hallucinations with extravagant
ideas, resembling somewhat those of general paralysis. In some cases the pic-
ture is that of ordinary delirium tremens, but the most peculiar and almost
characteristic mental disorder is that so well described by Wilks, in which the
patient loses all appreciation of time and place, and describes with circum-
stantial details long journeys which, he says, he has recently taken, or tells of
persons whom he has just seen. This is the so-called Korsakoff's syndrome.
(4) Multiple Neuritis in the Infectious Diseases. — This has been already
referred to, particularly in diphtheria, in which it is most common. The
peripheral nature of the lesion in these instances has been shown by post-
mortem examination. The outlook is usually favorable and, except in diph-
theria, fatal cases are uncommon. Multiple neuritis in tuberculosis, diabetes,
and s}qDhilis is of the same nature, being probably due to toxic materials
absorbed into the blood.
(5) The Metallic Poisons. — Neuritis from arsenic may follow: (a) The
medicinal use particularly of Fowler's solution. I have reported a case of
Hodgkin's disease in which general neuritis was caused by § j 3 ij of the
solution. In chorea a good many cases have been reported. Changes in the
nails are not uncommon, chiefly the transverse ridging. In one case in my
wards, of a young woman who had taken rough-on-rats, there were remarkable
white lines — the leuconychia — running across the nails, without any special
ridging. C. J. Aldrich finds that this is not uncommon in chronic arsenical
poisoning. (&) The accidental contamination of food or drink. Chrome
yellow may be used to color cakes, as in the cases recorded by D. D. Stewart.
A remarkable epidemic of neuritis occurred recently in the Midland Counties
of England, which was traced to the use of beer containing small quantities
of arsenic, a contamination from the sulphuric acid used in making glucose.
Some hundreds of cases occurred. Ee}Tiolds, who studied these cases, believes
that most of the instances of neuritis in drinkers are arsenical, but admits that
the slight cases may be due to the alcohol itself. Pigmentation of the skin is
an important distinguishing sign. The general features have been referred to
under arsenical poisoning. Lead is a much more frequent cause. Neuritis
has followed the use of mercurial inunctions. Zinc is a rare cause. I saw a
case with Dr. Urban Smith which followed the use of two grains of the
sulpho-carbolate taken daily for three years. Tea coffee, and tobacco are
mentioned as rare causes.
DISEASES OF THE PERIPHERAL NERVES. 1003
(6) Endemic Neuritis, Beri-heri, has been considered under the Infectious
Diseases.
Anesthesia Paralysis. — Here perhaps may most appropriately be con-
sidered the forms of paralysis following the use of anaesthetics, or of too
long-continued compression during operations. Much has been written in
the past few years upon this subject. There are two groups of cases :
1. During an operation the nerves may be compressed, either the brachial
plexus by the humerus or the musculo-spiral by the table. The pressure most
frequently occurs when the arm is elevated alongside the head, as in laparot-
omy done in the Trendelenburg position, or held out from the body, as in
breast amputations. Instances of paralysis of the crural nerves by leg-holders
are also reported. The too firm application of a tourniquet may be followed
by a severe paralysis.
2. Paralysis from cerebral lesions during etherization. In one of Gar-
rigues' cases paralysis followed the operation, and at the autopsy, seven weeks
later, softening of the brain was found. Apoplexy or embolism may occur
during ansesthesia. In Montreal a cataract operation was performed on an
old man. He did not recover from the anaesthetic; I found post mortem a
cerebral haemorrhage. A man was admitted to the Philadelphia Hospital, com-
pletely comatose, who on the previous day had been given ether for a minor
operation. He never recovered consciousness, but remained deeply comatose,
with great muscular relaxation, low temperature, 97.5°, and noisy respirations;
he died two days later. There was, unfortunately, no autopsy. Epileptic
convulsions may occur during the ansesthesia, and may even prove -fatal. The
possibility has to be considered of paralysis from loss of blood in prolonged
operations, though I have no personal knowledge of any such cases.
And, lastly, a paralysis might result from the toxic effects of the ether in
a very protracted administration.
Diagnosis. — The electrical condition in multiple neuritis is thus described
by Allen Starr : " The excitability is very rapidly and markedly changed ; but
the conditions which have been observed are quite various. Sometimes there
is a simple diminution of excitability, and then a very strong faradic or
galvanic current is needed to produce contractions. Frequently all faradic
excitability is lost and then the muscles contract to a galvanic current only.
In this condition it may require a very strong galvanic current to produce
contraction, and thus far it is quite pathognomonic of neuritis. For in an-
terior polio-myelitis, where the muscles respond to galvanism only, it does
not require a strong current to cause a motion until some months after the
invasion.
" The action of the different poles is not uniform. In many cases the con-
traction of the muscle when stimulated with the positive pole is greater than
when stimulated with the negative pole, and the contractions may be sluggish.
Then the reaction of degeneration is present. But in some cases the normal
condition is found and the negative pole produces stronger contractions than
the positive pole. A loss of faradic irritability and a marked decrease in the
galvanic irritability of the muscle and nerve are therefore important symp-
toms of multiple neuritis."
There is rarely any diflficulty in distinguishing the alcohol eases. The
combination of wrist and foot drop with congestion of the hands and feet.
1004 DISEASES OF THE NERVOUS SYSTEM.
and the peculiar delirium already referred to, is quite characteristic. The
rapidly advancing cases with paralysis of all extremities, often reaching to
the face and involving the sphincters, are more commonly regarded as of
spinal origin, but the general opinion seems to point strongly to the fact that
all such cases are peripheral. The less acute cases, in which the paralysis
gradually involves the legs and arms with rapid wasting, simulate closely and
are usually confounded with the subacute atrophic spinal paralysis of Du-
chenne. The diagnosis from locomotor ataxia is rarely difficult. The steppage
gait is entirely different from that of tabes. There is rarely positive incoor-
dination. The patient can usually stand well with the eyes closed. Foot-drop
is not common in locomotor ataxia. The lightning pains are absent and there
are no pupillary s}Tnptoms. The etiology, too, is of moment. The patient
is recovering from a paralysis which has been more extensive, or from arsen-
ical poisoning, or he has diabetes.
Treatment. — Eest in bed is essential. In the acute cases with fever, the
salicylates and antipyrin are recommended. To allay the intense pain morphia
or the hot applications of lead water and laudanum are often required. Great
care must be exercised in treating the alcoholic form, and the physician must
not allow himself to be deceived by the statements of the relatives. It is some-
times exceedingly difficult to get a history of spirit-drinking. In the alcoholic
form it is well to reduce the stimulants gradually. If there is any tendency
to bed-sores an air-bed should be used or the patient placed in a continuous
bath. Gentle friction of the muscles may be applied from the outset, and in
the later stages, when the atrophy is marked and the pains have lessened,
massage is probably the most reliable means at our command. Contrac-
tures may be gradually overcome by passive movements and extension. Often
with the most extreme deformity from contracture, recovery is, in time,
still possible. The interrupted current is useful when the acute stage is
passed.
Of internal remedies, strychnia is of value and may be given in increasing
doses. Arsenic also may be employed, and if there is a history of syphilis
the iodide of potassium and mercury may be given.
II. NEUROMATA.
Tumors situated on nerve fibres may consist of nerve substance proper, the
true neuromata, or of fibrous tissue, the false neuromata. The true neuroma
usually contains nerve fibres only, or in rare instances ganglion cells. Cases
of ganglionic or medullary neuroma are extremely rare; some of them, as
Lancereaux suggests, are undoubtedly instances of malformation of the brain
substance. In other instances, as in the case which I reported, the tumor is,
in all probability, a glioma with cells closely resembling those of the central
nervous system. The growths are often intermediate in their anatomical struc-
ture between the true and the false. Thomson's monograph, On Neuroma
and Neurofibromatosis (Edin., 1900), should be consulted.
(1) Plexiform Neuroma. — In this remarkable condition the various nerve
cords may be occupied by many hundreds of tumors. The eases are often
hereditary and usually congenital. The tumors may occur in all the nerves
of the body, and as numbers of them may be made out on palpation, the diag-
DISEASES OF THE PERIPHERAL NERVES. 1005
nosis is usually easy. One of the most remarkable cases is that described by
Prudden, the specimens of which are in the medical museum of Columbia
College, New York. There were over 1,182 distinct tumors distributed on the
nerves of the body. These tumors rarely are painful, but may cause symptoms
through pressure on neighboring structures.
(2) Generalized Neurofibromatosis: von Recklinghausen's Disease. — Spe-
cial attention was first directed to this particular form of multiple neuroma
by von Eecklinghausen in 1882. There are four essential features of the
malady :
(a) Soft, fibrous nodules, some sessile, others pedunculated, varying greatly
in size and number, are scattered over the surface of the body. These sub-
cutaneous growths at times may be diffuse and reach an enormous size, pro-
ducing a condition called " Elephantiasis Neuromatosa."
(&) Tumors resembling those of plexiform neuroma may be present on
any part of the nerve trunks from their central origin to the periphery. Their
variable situation may lead to a variety of symptoms, more especially as they
may arise from the nerve roots within the spinal canal or cranium. Superficial
painful nodules may also be present.
(c) Patches of brownish pigmentation of the skin, either as small spots or
large areas, are always present. Congenital nsevi are a frequent accompani-
ment of the disease.
(d) There are many variable sensory or motor phenomena resulting from
the presence of the nerve tumors, but peculiar mental changes, with loss of
intellectual power and sometimes difficulty in speaking, are especially charac-
teristic of the disease.
The prognosis depends on the possibility of successful removal of such
tumors as are causing greatest inconvenience. For a complete recent resume
of the subject see Adrian's review in the Cent. f. d. Grenzgebiete d. Med. u.
Chir., 1903.
(3) " TubercTila Dolorosa." — Multiple neuromata may especially affect the
terminal cutaneous branches of the sensory nerves and lead to small subcu-
taneous painful nodules, often found on the face, breast, or about the joints.
They may be associated with tumors of the nerve trunks.
(4) " Amputation Neuromata." — These bulbous swellings may form on
the central ends of nerves which have been divided in injuries or operations.
They are especially common after amputations. They are due to the tangled
coil of axis-cylinder processes growing down from the central stump in an
effort to reach their former end structures. They are very painful, and usually
require surgical removal, but often recur.
III. DISEASES OF THE CEREBRAL NERVES.
Olfactory Nerves and Tracts.
The functions of the olfactory nerves may be disturbed at their origin,
in the nasal mucous membrane, at the bulb, in the course of the tract, or
at the centres in the brain. The disturbances may be manifested in sub-
jective sensations of smell, complete loss of the sense, and occasionally in
hypersesthesia.
1006 DISEASES OF THE NERVOUS SYSTEM.
(a) Subjective Sensations; Parosmia. — Hallucinations of this kind are
found in the insane and in epileps}'. The aura may be represented by an
unpleasant odor, described as resembling chloride of lime, burning rags, or
feathers. In a few cases with these subjective sensations tumors have been
found in the hippocampi. In rare instances, after injury of the head the
sense is perverted — odors of the most different character may be alike, or the
odor may be changed, as in a patient noted by Morell Mackenzie, who for
some time could not touch cooked meat, as it smelt to her exactly like stink-
ing fish.
(&) Increased sensitiveness, or hyperosmia, occurs chiefly in nervous, hys-
terical women, in whom it may sometimes be developed so greatly that, like
a dog, they can recognize the difference between individuals by the odor alone.
(c) Anosmia; Loss of the Sense of Smell. — This may be produced by:
(1) Affections of the origin of the nerves in the mucous membrane, which
is perhaps the most frequent cause. It is by no means uncommon in asso-
ciation with chronic nasal catarrh and pol}^i. In paralysis of the fifth
nerve, the sense of smell may be lost on the affected side, owing to interfer-
ence with the secretion.
It is doubtful whether the cases of loss of smell following the inhalations
of very foul or strong odors should come under this or under the central
division.
(2) Lesions of the bulbs or of the tracts. In falls or blows, in caries
of the bones, and in meningitis or tumor, the bulbs or the olfactory tracts
may be involved. After an injury to the head the loss of smell may be the
only symptom. j\Iackenzie notes a case of a surgeon who was thrown from
his gig and lighted on his head. The injury was slight, but the anosmia
which followed was persistent. In locomotor ataxia the sense of smell may
be lost, possibly owing to atrophy of the nerves.
(3) Lesions of the olfactory centres. There are congenital cases in which
the structures have not been developed. Cases have been reported by Beevor,
Hughlings Jackson, and others, in which anosmia has been associated with
disease in the hemisphere. The centre for the sense of smell is placed by
Ferrier in the uncinate gyrus. Flechsig describes (1) a frontal centre in the
base of the frontal lobe and (2) a temporal centre in the uncus.
To test the sense of smell the pungent bodies, such as ammonia, which
act upon the fifth nerve, should not be used, but such substances as cloves,
peppermint, and musk. This sense is readily tested as a routine matter in
brain cases by having two or three bottles containing the essential oils. In
all instances a rhinoscopical examination should be made, as the condition
may be due to local, not central causes. The treutment is unsatisfactory
even in the cases due to local lesions in the nostrils.
Optic Nerve axd Tract.
(1) Lesions of the Retiyia.
These are of importance to the physician, and information of the great-
est value may be obtained by a systematic examination of the eye-grounds.
Only a brief reference can here be made to the more important of the appear-
ances.
DISEASES OF THE PERIPHERAL NERVES. 1007
(a) Retinitis. — This occurs in certain general affections, more particu-
larly in Bright's disease, syphilis, leukgemia, and aneemia. The common
feature in all these states is the occurrence of hgemorrhage and the develop-
ment of opacities. There may also be a diffuse cloudiness due to effusion
of serum. The haemorrhages are in the layer of nerve fibres. They vary
greatly in size and form, but often follow the course of vessels. When recent
the color is bright red, but they gradually change and old hgemorrhages are
almost black. The white spots are due either to fibrinous exudate or to fatty
degeneration of the retinal elements, and occasionally to accumulation of leu-
cocytes or to a localized sclerosis of the retinal elements. The more important
of the forms of retinitis to be recognized are :
Albuminuric retinitis, which occurs in chronic nephritis, particularly in
the interstitial or contracted form. The percentage of cases affected is from
15 to 25. There are instances in which these retinal changes are associated
with the granular kidney at a stage when the amount of albumin may be
slight or transient; but in all such instances it will be found that there is a
marked arterio-sclerosis. Gowers recognizes a degenerative form (most com-
mon), in which, with the retinal changes, there may be scarcely any alteration
in the disk; a hsemorrhagic form, with many hsemorrhages and but slight
signs of inflammation; and an inflammatory form, in which there is much
swelling of the retina and obscuration of the disk. It is noteworthy that in
some instances the inflammation of the optic nerve predominates over the
retinal changes, and one may be in doubt for a time whether the condition is
really associated with the renal changes or dependent upon intracranial
disease.
Syphilitic Retinitis. — In the acquired form this is less common than cho-
roiditis. In inherited syphilis retinitis pigmentosa is sometimes met with.
Retinitis in Ancemia. — It has long been known that a patient may become
blind after a large haemorrhage, either suddenly or within two or three days,
and in one or both eyes. Occasionally the loss may be permanent and com-
plete. In some of these instances a neuro-retinitis has been found, probably
sufficient to account for the symptoms. In the more chronic anaemias, par-
ticularly in the pernicious form, retinitis is common, as determined first by
Quincke.
In malaria retinitis or neuro-retinitis may be present, as noted by Stephen
Mackenzie. It is seen only in the chronic cases with anaemia, and in my
experience is not nearly so common proportionately as in pernicious angemia.
Leuhcemic Retinitis. — In this affection the retinal veins are large and dis-
tended; there is also a peculiar retinitis, as described by Liebreich. It is
not very common. It existed in only 3 of 10 cases of which I have notes of
examination of the retina. There are numerous hsemorrhages and white or
yellow areas, which may be large and prominent. In one of my cases the
retina post mortem was dotted with many small, opaque, white spots, looking
like little tumors, the larger of which had a diameter of nearly 2 mm. In Case
13 of my series the leukaemia was diagnosed from the condition of the eye-
grounds alone, by JSTorris and De Schweinitz, at whose clinic the patient had
applied on account of failing vision.
Retinitis is also found occasionally in diabetes, in purpura, in chronic
lead poisoning, and sometimes as an idiopathic affection.
1008 DISEASES OF THE NERVOUS SYSTEM.
(h) Functional Disturbances of Vision. — (1) Toxic Amaurosis. — This
occvirs in uraemia and may follow convulsions or come on independentl3^
The condition, as a rule, persists only for a day or two. This form of amau-
rosis occurs in poisoning by lead, alcohol, and occasionally by quinine. It
seems more probable that the poisons act on the centres and not on the retina.
(2) Tolacco Amtlyopia. — The loss of sight is usually gradual, equal in
both eyes, and affects particularly the centre of the field of vision. The eye-
grounds may be normal, but occasionally there is congestion of the disks.
On testing the color fields a central scotoma for red and green is found in all
cases. Ultimately, if the use of tobacco is continued, organic changes may
develop with atrophy of the disk.
(3) Hysterical Amaurosis. — More frequently this is loss of acuteness of
vision — amblyopia — but the loss of sight in one or both eyes may apparently
be complete. The condition will be mentioned subsequently under hysteria.
(4) NigM-llindness — nyctalopia — ^the condition in which objects are
clearly seen during the day or by strong artificial light, but become invisible
in the shade or in twilight, and hemeralopia, in which objects can not be
clearly seen without distress in daylight or in a strong artificial light, but
are readily seen in a deep shade or in twilight, are functional anomalies of
vision which rarely come under the notice of the physician. It may occur
in epidemic form,
(5) Retinal hypercestliesia is sometimes seen in hysterical women, but is
not found frequently in actual retinitis. I have seen it once, however, in
albuminuric retinitis, and once, in a marked degree, in a patient with aortic
insufficiency, in whose retinaB there were no signs other than the throbbing
arteries,
(2) Lesions of the Optic Nerve.
(a) Optic Neuritis (Papillitis; Clio'ked DisJc). — In the first stage there is
congestion of the disk and the edges are blurred and striated. In the second
stage the congestion is more marked; the swelling increases, the striation
also is more visible. The phj^siological cupping disappears and hsemorrhages
are not uncommon. The arteries present little change, the veins are dilated,
and the disk may swell greatly. In slight grades of inflammation the swelling
gradually subsides and occasionally the nerve recovers completely. In in-
stances in which the swelling and exudate are very great, the subsidence is
slow, and when it finally disappears there is complete atrophy of the nerve.
The retina not infrequently participates in the inflammation, which is then
a neuro-retinitis.
This condition is of the greatest importance in diagnosis. It may exist
in its early stages without any disturbance of vision, and even with exten-
sive papillitis the sight may for a time be good.
Optic neuritis is seen occasionally in angemia and lead poisoning, more
commonly in Bright's disease as neuro-retinitis. It occurs occasionally as
a primary idiopathic affection. The frequent connection with intracranial
disease, particularly tumor, makes its presence of great value to practition-
ers. The nature of the growth is without influence. In over 90 per cent
of such instances the papillitis is bilateral. It is also found in meningitis,
either the tuberculous or the simple form. In meningitis it is easy to see
DISEASES OF THE PERIPHERAL NERVES. 1009
how the inflammation may extend down the nerve sheath. In the case of
tumor, however, it is probable that mechanical conditions, especially the
venous stasis, are alone responsible for the oedematous swelling. It often sub-
sides very rapidly after a palliative craniectomy has been performed.
(h) Optic Atrophy. — This may be: (1) A primary affection. There is
an hereditary form, in which the disease has developed in all the males of a
family shortly after puberty. A large number of the cases of primary atrophy
are associated with spinal disease, particularly locomotor ataxia. Other causes
which have been assigned for the primary atrophy are cold, sexual excesses,
diabetes, the specific fevers, alcohol, and lead.
(2) Secondary atrophy results from cerebral diseases, pressure on the
chiasma or on the nerves, or, most commonly of all, as a sequence of papillitis.
The ophthalmoscopic appearances are different in the cases of primary
and secondary atrophy. In the former, the disk has a gray tint, the edges
are well defined, and the arteries look almost normal; whereas in the con-
secutive atrophy the disk has a staring opaque-white aspect, with irregular
outlines, and the arteries are very small.
The symptom of optic atrophy is loss of sight, proportionate to the dam-
age in the nerve. The change is in three directions : " ( 1 ) Diminished acuity
of vision; (2) alteration in the field of vision; and (3) altered perception of
color" (Gowers). The outlook in primary atrophy is bad.
(3) Affections of the Chiasma and Tract.
At the chiasma the optic nerves undergo partial decussation. Each optic
tract, as it leaves the chiasma, contains nerve fibres which originate in the
retinae of both eyes. Thus, of the fibres of the right tract, part have come
through the chiasma without decussating from the temporal half of the right
retina, the other and larger portion of the fibres of the tract have decussated
in the chiasma, coming as they do from the left optic nerve and the nasal half
of the" retina on the left side. The fibres which cross are in the middle por-
tion of the chiasma, while the direct fibres are on each side. The following
are the most important changes which ensue in lesions of the tract and of the
chiasma :
(a) Unilateral Affection of Tract. — If on the right side, this produces
loss of function in the temporal half of the retina on the right side, and in
the nasal half of the retina on the left side, so that there is only half vision,
and the patient is blind to objects on the left side. This is termed homony-
mous hemianopia or lateral hemianopia. The fibres passing to the right
half of each retina being involved, the patient is blind to objects in the
left half of each visual field. The hemianopia may be partial and only a
portion of the half field may be lost. The unaffected visual fields may have
the normal extent, but in some instances there is considerable reduction.
When the left half of one field and the right half of the other, or vice versa,
are blind, the condition is known as heteronymous hemianopia.
(&) Disease of the Chiasma. — (1) A lesion involves, as a rule, chiefly
the central portion, in which the decussating fibres pass which supply the
inner or nasal halves of the retinas, producing in consequence loss of vision
in the outer half of each field, or what is known as temporal hemianopia.
65
1010 DISEASES OF THE NERVOUS SYSTEM,
(2) If the lesion is more eztensive it may involve not only the central por-
tion, but also the direct fibres on one side of the commissure, in which case
there would be total blindness in one eye and temporal hemianopia in the
other.
(3) Still more extensive disease is not infrequent from pressure of tumors
in this region, the whole chiasma is involved, and total blindness results. The
different stages in the process may often be traced in a single case from tem-
poral hemianopia, then complete blindness in one eye with temporal hemi-
anopia in the other, and finally complete blindness.
(4) A limited lesion of the outer part of the chiasma involves only the
direct fibres passing to the temporal halves of the retinae and inducing blind-
ness in the nasal field, or, as it is called, nasal hemianopia. This, of course, is
extremely rare. Double nasal hemianopia may occur as a manifestation of
tabes and in tumors involving the outer fibres of each tract.
(4) Affections of the Tract and Centres.
The optic tract crosses the crus (cerebral peduncle) to the hinder part
of the optic thalamus and divides into two portions, one of which (the lateral
root) goes to the pulvinar of the thalamus, the lateral geniculate body, and
to the anterior quadrigeminal body (superior colliculus). From these parts,
in which the lateral root terminates, fibres pass into the posterior part of the
internal capsule and enter the occipital lobe, forming the fibres of the optic
radiation, which terminate in and about the cuneus, the region of the visual
perceptive centre. The fibres of the medial division of the tract pass to the
medial geniculate body and to the posterior quadrigeminal body. The medial
root contains the fibres of the commissura inferior of v. Gudden, which are
believed to have no connection with the retinae. It is still held by some physi-
ologists that the cortical visual centre is not confined to the occipital lobe alone,
but embraces the occipito-angular region.
A lesion of the fibres of the optic path anywhere between the cortical cen-
tre and the chiasma will produce hemianopia. The lesion may be situated:
{a) In the optic tract itself. (&) In the region of the thalamus, lateral
geniculate body, and the corpora quadrigemina, into which the larger part of
each tract enters, (c) A lesion of the fibres passing from the centres just
mentioned to the occipital lobe. This may be either in the hinder part of the
internal capsule or the white fibres of the optic radiation, {d) Lesion of the
cuneus. Bilateral disease of the cuneus may result in total blindness, (e)
There is clinical evidence to show that lesion of the angular gyrus may be
associated with visual defect, not so often hemianopia as crossed amblyopia,
dimness of vision in the opposite eye, and great contraction in the field of
vision. Lesions in this region are associated with mind-blindness, a condition
in which there is failure to recognize the nature of objects.
The effects of lesions in the optic nerve in different situations from the reti-
nal expansion to the brain cortex are as follows: (1) Of the optic nerve — total
blindness of the corresponding eye; (2) of the optic chiasma, either temporal
hemianopia, if the central part alone is involved, or nasal hemianopia, if the
lateral region of each chiasma is involved; (3) lesion of the optic tract
between the chiasma and the lateral geniculate body produces lateral
DISEASES OF THE PERIPHERAL NERVES.
1011
hemianopia ; (4) lesion of the central fibres of the nerve between the genicu-
late bodies and the cerebral cortex produces lateral hemianopia; (5) lesion of
the cuneus causes lateral hemianopia; and (6) lesion of the angular gyrus
may be associated with hemianopia, sometimes crossed amblyopia, and the con-
dition known as mind-blindness. (See Fig. 10, with accompanying expla-
nation.)
Fig. 10. — Diagram of visual paths. (Prom Vialet, modified.) OP. N., Optic nerve. OP. C.
Optic chiasm. OP, T., Optic tract. OP. R., Optic radiations. EXT. GEN., External
geniculate body. THO., Optic thalamus. C. QU., Corpora quadrigemina. C. C, Corpus
callosum. V. S., Visual speech centre. A. S., Auditory speech centre. M. S., Motor
speech centre. A lesion at 1 causes blindness of that eye ; at 2, bi-temporal hemianopia ;
at 3, nasal hemianopia. Symmetrical lesions at 3 and 3' would cause bi-nasal hemia-
nopia ; at 4, hemianopia of both eyes, with hemianopic pupillary inaction ; at 5 or 6,
hemianopia of both eyes, pupillary reflexes normal ; at 7, amblyopia, especially of oppo-
site eye ; at 8, on left side, word-blindness.
Diagnosis of the Optic Nerve and Tract. — The student or practitioner must
have a clear idea of the physiology of the nerve-centres before he can appre-
ciate the symptoms or undertake the diagnosis of lesions of the optic nerve.
1012 DISEASES OF THE NERVOUS SYSTEM.
Having determined the presence of iiemianopia, the question arises as to the
situation of the lesion, whether in the tract between the chiasma and the genic-
ulate bodies or in the central portion of the fibres between these bodies and the
visual centres. This can be determined in some cases by the test known as Wer-
nicke's hemiopic pupillary inaction. The pupil reflex depends on the in-
tegrity of the retina or receiving membrane, on the fibres of the optic nerve
and tract which transmit the impulse, and the nerve-centre at the termination
of the optic tract which receives the impression and transmits it to the third
nerve along which the motor impulses pass to the iris. If a bright light is
thrown into the eye and the pupil reacts, the integrity of this reflex arc is
demonstrated. It is possible in cases of lateral hemianopia so to throw the
light into the eye that it falls upon the blind half of the retina. If when this
is done the pupil contracts, the indication is that the reflex arc above referred
to is perfect, by which we mean that the optic nerve fibres from the retinal
expansion to the centre, the centre itself, and the third nerve are uninvolved.
In such a case the conclusion would be justified that the cause of the hemi-
anopia was central ; that is, situated beyond the geniculate body, either in the
fibres of the optic radiation or in the visual cortical centres. If, on the other .
nand, when the light is carefully throvm on the hemiopic half of the retina,
the pupil remains inactive, the conclusion is justifiable that there is interrup-
tion in the path between the retina and the nucleus of the third nerve, and that
the hemianopia is not central, but dependent upon a lesion situated in the
optic tract. This test of Wernicke's is sometimes difficult to obtain. It is
best performed as follows : " The patient being in a dark or nearly dark room
with the lamp or gas-light behind his head in the usual position, I bid him
look over to the other side of the room, so as to exclude accommodative iris
movements (which are not necessarily associated with the reflex). Then I
throw a faint light from a plane mirror or from a large concave mirror, held
well out of focus, upon the eye and note the size of the pupil. With my other
hand I now throw a beam of light, focussed from the lamp by an ophthalmo-
scopic mirror, directly into the optical centre of the eye; then laterally in
various positions, and also from above and below the equator of the eye, noting
the reaction at all angles of incidence of the ray of light " (Seguin) .
The significance of hemianopia varies. There is a functional hemianopia
associated with migraine and hysteria. In a considerable proportion of all
cases there are signs of organic brain-disease. In a certain number of in-
stances of slight lesions of the occipital lobe hemichromatopsia has been
observed. The homomnnous halves of the retina as far as the fix:ation point
are dulled, or blind for colors. Hemiplegia is common, in which event the
loss of power and blindness are on the same side. Thus, a lesion in the left
hemisphere involving the motor tract produces right hemiplegia, and when
the fibres of the optic radiation are involved in the internal capsule, there is
also lateral hemianopia, so that objects in the field of vision to the right are
not perceived. Hemiangesthesia is not uncommon in such cases, owing to the
close association of the sensory and visual tracts at the posterior part of the
internal capsule. Certain forms of aphasia also occur in many of the cases.
The optic aphasia of Freund may be mentioned here. The patient after
an apoplectic attack, though able to recognize ordinary objects shown to him
is unable to name them correctly. If he be permitted to touch the object he
DISEASES OF THE PERIPHERAL NERVES. 1013
may be able to name it quickly and correctly. Freund's optic aphasia differs
from mind-blindness, since in the latter afEection the objects seen are not
recognized. Optic aphasia, like word-blindness, never occurs alone, but is
always associated with hemianopia, or mind-blindness, and often also with
word-deafness. In the cases which have thus far come to autopsy there has
always been a lesion in the white matter of the occipital lobe on the left side.
Motor Nerves of Tut Eyeball.
Third Nerve (Nervus oculomotorius) . — The nucleus of origin of this nerve
is situated in the floor of the aqueduct of Sylvius; the nerve passes through
the crus at the side of which it emerges. Passing along the wall of the cav-
ernous sinus, it enters the orbit through the sphenoidal fissure and supplies,
by its superior branch, the levator palpebrae superioris and the superior rectus,
and by its inferior branch the internal and inferior recti muscles and the infe-
rior oblique. Branches pass to the ciliary muscle and the constrictor of the
iris. Lesions may affect the nucleus or the nerve in its course and cause either
paralysis or spasm.
Paralysis. — A nuclear lesion is usually associated with the disease of the
centres for the other eye muscles, producing a condition of general ophthal-
moplegia. More commonly the nerve itself is involved in its course, either by
meningitis, gummata, or aneurism, or is attacked by a neuritis, as in diph-
theria and locomotor ataxia. Complete paralysis of the third nerve is accom-
panied by the following symptoms :
Paralysis of all the muscles, except the superior oblique and external rec-
tus, by which the eye can be moved outward and a little downward and inward.
There is divergent strabismus. There is ptosis or drooping of the upper eye-
lid, owing to paralysis of the levator palpebrge. The pupil is usually dilated.
It does not contract to light, and the power of accommodation is lost. The
most striking features of this paralysis are the external strabismus, with
diplopia or double vision, and the ptosis. In very many cases the affection
of the third nerve is partial. Thus the levator palpebrae and the superior
rectus may be involved together, or the ciliary muscles and the iris may be
affected and the external muscles may escape.
There is a remarkable form of recurring oculo-motor paralysis affecting
chiefly women, and involving all the branches of the nerve. In some cases
the attacks have come on at intervals of a month; in others a much longer
period has elapsed. The attacks may persist throughout life. They are some-
times associated with pain in the head and sometimes with migraine. Mary
Sherwood has collected from the literature 23 cases.
Ptosis is a common and important symptom in nervous affections. We
may here briefly refer to the conditions under which it may occur : (a) A con-
genital, incurable form, which is frequently seen; (&) the form associated
with definite lesion of the third nerve, either in its course or at its nucleus.
This may come on with paralysis of the superior rectus alone or with paralysis
of the internal and inferior recti as well, (c) There are instances of com-
plete or partial ptosis associated with cerebral lesions without any other branch
of the third nerve being paralyzed. The exact position of the cortical centre
or centres is as yet unknown, (d) Hysterical ptosis, which is double and
1014 DISEASES OF THE NERVOUS SYSTEM.
occurs with other hysterical s}Tnptoins. (e) Pseudo-ptosis, due to affection
of the s}Tapathetic nerve, is associated with symptoms of vaso-motor palsy,
such as elevation of the temperature on the affected side with redness and
oedema of the skin. Contraction of the pupil exists on the same side and the
eyeball appears rather to have shrunk into the orbit, (f) In idiopathic mus-
cular atrophy, when the face muscles are involved, there may be marked
bilateral ptosis. And, lastly, in weak, delicate women there is often to be
seen a transient ptosis, particularly in the morning.
Among the most important of the symptoms of the third-nerve paralysis
are those which relate to the ciliary muscle and iris.
Ctcloplegia, paralysis of the ciliary muscle, causes loss of the power of
accommodation. Distant vision is clear, but near objects can not be prop-
erly seen. In consequence the vision is indistinct, but can be restored by the
use of convex glasses. This may occur in one or in both eyes; in the latter
case it is usually associated with disease in the nuclei of the nerve. Cyclo-
plegia is an early and frequent symptom in diphtheritic paralysis and occurs
also in tabes.
Iridoplegia, or paralysis of the iris, occurs in three forms (Gowers).
(a) Accommodation iridoplegia, in which the pupil does not diminish in
size during the act of accommodation. To test for this the patient should
look first at a distant and then at a near object in the same line of vision.
(h) Reflex Iridoplegia. — The path for the iris reflex is along the optic
nerve and tract to its termination, then to the nucleus of the third nerve,
and along the trunk of this nerve to the ciliary ganglion, and so through
the ciliary nerves to the eyes. Each eye should be tested separately, the other
one being covered. The patient should look at a distant object in a dark part
of the room; then a light is brought suddenly in front of the eye at a dis-
tance of three or four feet, so as to avoid the effect of accommodation. Loss
of this iris reflex with retention of the accommodation contraction is known
as the Arg}dl Eobertson pupil.
(c) Loss of the Shin Reflex. — If the skin of the neck is pinched or pricked
the pupil dilates reflexly, the aft'erent impulses being conveyed along the cer-
vical sympathetic. Erb pointed out that this skin reflex is lost usually in
association with the reflex contraction, but the two are not necessarily con-
joined. In iridoplegia the pupils are often small, particularly in spinal dis-
ease, as in the characteristic small pupils of tabes — spinal myosis. Irido-
plegia may coexist with a pupil of medium size.
Inequality of the pupils — anisocoria — is not infrequent in progressive pare-
sis and in tabes. It may also occur in perfectly healthy individuals.
Spasm. — Occasionally in meningitis and in hysteria there is spasm of the
muscles supplied by the third nerve, particularly the internal rectus and the
levator palpebrse. The clonic rhythmical spasm of the eye muscles is known
as nystagmus, in which there is usually a bilateral, rhythmical, involuntary
movement of the eyeballs. The condition is met with in many congenital
and acquired brain lesions, in albinism, and sometimes in coal-miners.
Fourth. Nerve {Nervus trochlearis) . — This supplies the superior oblique
muscle. In its course around the outer surface of the crus and in its pas-
sage into the orbit it is liable to be compressed by tumors, by aneurism, or in
the exudation of basilar meningitis. Its nucleus in the upper part of the
DISEASES OF THE PERIPHERAL NERVES. 1015
fourth ventricle may be involved by tumors or undergo degeneration with the
other ocular nuclei. The superior oblique muscle acts in such a way as to direct
the eyeball downward and rotate it slightly. The paralysis causes defective
downward and inward movement, often too slight to be noticed. The head is
inclined somewhat forward and toward the sound side, and there is double
vision when the patient looks down.
Sixth Nerve (Nervus abducens) . — ^This nerve emerges at the junction of
the pons and medulla, then, passing forward, it enters the orbit and supplies
the external rectus muscle. Owing to its long course and exposed position it
is more commonly injured than any other cranial nerve. It is affected by
meningitis at the base, by gummata or other tumors, and sometimes by cold.
There is internal strabismus, and the eye can not be turned outward. Diplopia
occurs on looking toward the paralyzed side.
" When the nucleus is affected there is, in addition to paralysis of the
external rectus, inability of the internal rectus of the opposite eye to turn that
eye inward. As a consequence of this the axes of the eyes are kept parallel,
and both are conjugately deviated to the opposite side, away from the side
of lesion. The reason of this is that the nucleus of the sixth nerve sends
fibres up in the pons to that part of the nucleus of the opposite third nerve
which supplies the internal rectus. We thus have paralysis of the internal
rectus without the nucleus of the third nerve being involved, owing to its
receiving its nervous impulses for parallel movement from the sixth nucleus
of the opposite side. As the sixth nucleus is in such proximity to the facial
nerve in the substance of the pons, it is frequently found that the whole of
the face on the same side is paralyzed, and gives the electrical reaction of
degeneration, so that with a lesion of the left sixth nucleus there is conjugate
deviation of both eyes to the right — i. e., paralysis of the left external and the
right internal rectus, and sometimes complete paralysis of the left side of the
face" (Beevor).
General Features of Paralysis of the Motor Nerves of the- Eye. — Gowers
divides them into five groups :
(a) Limitation of Movement. — Thus, in paralysis of the external rectus,
the eyeball can not be moved outward. When the paralysis is incomplete
the movement is deficient in proportion to the degree of the palsy,
(&) Strabismus. — The axes of the eyes do not correspond. Thus, paral-
ysis of the internal rectus causes a divergent squint; of the external rectus,
a convergent squint. At first this is evident only when the eyes are moved
in the direction of the action of the weak muscle, but may become con-
stant by the contraction of the opposing muscle. The deviation of the axis
of the affected eye from parallelism with the other is called the primary
deviation.
(c) Secondary Deviation. — If, while the patient is looking at an object,
the sound eye is covered, so that he fixes the object looked at with the affected
eye only, the sound eye is moved still further in the same direction — e. g.,
outward, when there is paralysis of the opposite internal rectus. This is known
as secondary deviation. It depends upon the fact that, if two muscles are
acting together, when one is weak and an effort is made to contract it, the
increased effort — innervation — acts powerfully upon the other muscle, causing
an increased contraction.
1016 DISEASES OF THE NERVOUS SYSTEM.
(d) Erroneous Projection. — "We judge of the relation of external ob-
jects to each other by the relation of their images on the retina; but we judge
of their relation to our own body by the position of the e5^eball as indicated
to us by the innervation we give to the ocular muscles" (Gowers). With
the eyes at rest in the mid-position, an object at which we are looking is
directly opposite our face. Turning the eyes to one side, we recognize that
object in the middle of the field or to the side of this former position. We
estimate the degree by the amount of movement of the eyes, and when the
object moves and we follow it we judge of its position by the amount of move-
ment of the eyeballs. When one ocular muscle is weak, the increased inner-
vation gives the impression of a greater movement of the eye than has really
taken place. The mind, at the same time, receives the idea that the object is
further on one side than it really is, and in an attempt to touch it the finger
may go beyond it. As the equilibrium of the body is in a large part main-
tained by a knowledge of the relation of external objects to it obtained by the
action of the eye muscles, this erroneous projection resulting from paralysis
disturbs the harmony of these visual impressions and may lead to giddiness —
ocular vertigo.
(e) Double Vision. — This is one of the most disturbing features of paral-
ysis of the eye muscles. The visual axes do not correspond, so that there is
a double image — diplopia. That seen by the sound eye is termed the true
image; that by the paralyzed eye, the false. In simple or homonjinous
diplopia the false image is " on the same side of the other as the eye by which
it is seen." In crossed diplopia it is on the other side. In convergent squint
the diplopia is simple: in divergent it is crossed.
Ophthalmoplegia. — Under this term is described a chronic progressive
paralysis of the ocular muscles. Two forms are recognized — ophthalmoplegia
externa and ophthalmoplegia interna. The conditions may occur separately
or together and are described by Gowers under nuclear ocular palsy.
Ophthalmoplegia externa. — The condition is one of more or less com-
plete palsy of the external muscles of the eyeball, due usually to a slow degen-
eration in the nuclei of the nerves, but sometimes to pressure of tumors or to-
basilar meningitis. It is often, but not necessarily, associated with ophthal-
moplegia interna. Siemerling, in a monograph on the subject, states that 6^
cases are on record. In only 11 of these could s^^jhilis be positively deter-
mined. The levator muscles of the eyelids and the superior recti are first
involved, and gradually the other muscles, so that the eyeballs are fixed and
the eyelids droop. There is sometimes slight protrusion of the e3^eballs. The
disease is essentially chronic and may last for many years. It is found par-
ticularly in association with general paralysis, locomotor ataxia, and in pro-
gressive muscular atrophy. Mental disorders were present in 11 of the 62
cases. With it may be associated atrophy of the optic nerve and affections of
other cerebral nerves. Occasionally, as noted by Bristowe, it may be func-
tional.
Ophthalmoplegia ixteexa. — Jonathan Hutchinson applied this term to
a progressive paralysis of the internal ocular muscles, causing loss of pupil-
lary action and the power of accommodation. When the internal and ex-
ternal muscles are involved the affection is known as total ophthalmoplegia,
and in a majority of the cases the two conditions are associated. In some
DISEASES OF THE PERIPHERAL NERVES. 1017
instances the internal form may depend upon disease of the ciliary gan-
glion.
While, as a rule, opthalmoplegia is a chronic process, there is an acute
form associated with hsemorrhagic softening of the nuclei of the ocular mus-
cles. There is usually marked cerebral disturbance. It was to this form that
Wernicke gave the name poliencephalitis superior.
Treatment of Ocular Palsies. — It is important to ascertain, if possible,
the cause. The forms associated with locomotor ataxia are obstinate, and
resist treatment. Occasionally, however, a palsy, complete or partial, may
pass away spontaneously. The group of cases associated with chronic degen-
erative changes, as in progressive paresis and bulbar paralysis, is little affected
by treatment. On the other hand, in syphilitic cases, mercury and iodide of
potassium are indicated and are often beneficial. Arsenic and strychnia, the
latter hypodermically, may be employed. In any case in which the onset is
acute, with pain, hot fomentations and counter-irritation or leeches applied
to the temple give relief. The direct treatment by electricity has been exten-
sively employed, but probably without any special effect. The diplopia may
be relieved by the use of prisms, or it may be necessary to cover the affected eye
with an opaque glass.
Fifth J^erve (Nervus trigeminus).
Paralysis may result from: (a) Disease of the pons, particularly hemor-
rhage or patches of sclerosis, (h) Injury or disease at the base of the brain.
Fracture rarely involves the nerve; on the other hand, meningitis, acute or
chronic, and caries of the bone are not uncommon causes, (c) The branches
may be affected as they pass out — the first division by tumors pressing on the
cavernous sinus or by aneurism; the second and third divisions by growths
which invade the spheno-maxillary fossa. (d) Primary neuritis, which
is rare.
Symptoms. — (a) Sensory Portion. — Disease of the fifth nerve may cause
loss of sensation in the parts supplied, including the half of the face, the cor-
responding side of the head, the conjunctiva, the mucosa of the lips, tongue,
hard and soft palate, and of the nose of the same side. The anaesthesia may
be preceded by tingling or pain. The muscles of the face are also insensible
and the movements may be slower. The sense of smell is interfered with,
owing to dryness of the mucous membrane. There may be disturbance of
the sense of taste. The salivary, lachrymal, and buccal secretions may be
lessened, and the teeth may become loose. Unless properly guarded from
injury an ulcerative inflammation of the eye may follow. This was formerly
supposed to be due to nutritional changes from paralysis of so-called trophic
nerve fibres. This idea has of late years been overthrown by the large number
of cases in which the Gasserian ganglion has been removed for obstinate
neuralgia without consequent inflammation of the eye. Herpes may develop
in the region supplied by the nerve, usually the upper branch, and is asso-
ciated with much pain, which may be peculiarly enduring, lasting for
months or years (Gowers). In herpes zoster with the neuritis there may be
slight enlargement of the cervical glands, (See under JSTeuralgia for Tic
Douloureux.)
1018 DISEASES OF THE NERVOUS SYSTEM.
(i) Motor Poetiox. — The inability to use the muscles of mastication on
the affected side is the distinguishing feature of paralysis of this portion of
the nerve. It is recognized by placing the finger on the masseter and tem-
poral muscles, and, when the patient closes the jaw, the feebleness of their
contraction is noted. If paralyzed, the external pterygoid can not move the
jaw toward the unaffected side; and when depressed, the jaw deviates to the
paralyzed side. The motor paralysis of the fifth nerve is almost invariably a
result of involvement of the nerve after it has left the nucleus. Cases, however,
have been associated with cortical lesions. The cortical motor centre for the
trigeminus, or for movements effecting closure of the jaw, lies below that for
movements of the face at the lower part of the anterior central convolution.
Spasm of the Muscles of Mastication. — Trismus, the masticatory spasm
of Eomberg, may be tonic or clonic, and is either an associated phenomenon
in general convulsions or, more rarely, an independent affection. In the tonic
form the jaws are kept close together — ^lock-jaw — or can be separated only for
a short space. The muscles of mastication can be seen in contraction and
felt to be hard; the spasm is often painful. This tonic contraction is an
early s}Tnptom in tetanus, and is sometimes seen in tetany. A form of this
tonic spasm occurs in hysteria. Occasionally trismus follows exposure to cold,
and is said to be due to reflex irritation from the teeth, the mouth, or caries
of the jaw. It may also be a symptom of organic disease due to irritation
near the motor nucleus of the fifth nerve.
Clonic spasm of the muscles supplied by the fiith occurs in the form of
rapidly repeated contractions, as in '"' chattering teeth."' This is rare apart
from general conditions, though cases are on record, usually in women late
in life, in whom this isolated clonic spasm of the muscles of the jaw has been
found. In another form of clonic spasm sometimes seen in chorea, there are
forcible single contractions. Gowers mentions an instance of its occurrence as
an isolated affection.
(c) GusTATOET. — Complete or partial loss of the sense of taste over the
anterior two-thirds of the tongue has been supposed by some to follow paralysis
of the fifth nerve. There are two views concerning the course of the fibres that
carry gustatory impulse from this part of the tongue. According to some
they take a devious path, passing with the chorda tjmpani to the geniculate
ganglion, thence by the great superficial petrosal nerve to Meckel's ganglion,
and this they leave to reach the maxillary nerve, which they follow through the
trigeminal nerve to the brain. A study of clinical cases of disease of the fifth
nerve has led to this view. It seems more probable, however, from the fact
that a large number of the trigeminal neurectomies are not followed by loss of
taste, that the fibres pass to the brain directly from the geniculate ganglion
by the nervus intermedins of Wrisberg. Possibly there may be more than one
course for these fibres.
The diagnosis of disease of the trifacial nerve is rarely difficult. It must
be remembered that the preliminary pain and h}'per£esthesia are sometimes
mistaken for ordinary neuralgia. The loss of sensation and the palsy of the
muscles of mastication are readily determined.
Treatment. — When the pain is severe morphia may be required and local
applications are useful. If there is a suspicion of sj^hilis, appropriate treat-
ment should be siven. Faradization is sometimes beneficial.
DISEASES OF THE PERIPHERAL NERVES. 1019
Facial Nerve,
Paralysis {Bell's Palsy). — The facial or seventh may be paralyzed by (1)
lesions of the cortex — supranuclear palsy; (2) lesions of the nucleus itself;
or (3) involvement of the nerve trunk in its tortuous course within the pona
and through the wall of the skull.
1. Supranuclear paralysis, due to lesion of the cortex or of the facial fibres
in the corona radiata or internal capsule, is, as a rule, associated with hemi-
plegia. It may be caused by tumors, abscess, chronic inflammation, or soften-
ing in the cortex or in the region of the internal capsule. It is distinguished
from the peripheral form by well-marked characters — the persistence of the
normal electrical excitability of both nerves and muscles and the frequent
absence of involvement of the upper branches of the nerve, so that the orbicu-
laris palpebrarum, frontalis, and corrugator muscles are spared. In rare
instances these muscles are paralyzed. In this form the voluntary movements
are more impaired than the emotional. Isolated paralysis — monoplegia
facialis — due to involvement of the cortex or of the fibres in their path to
the nucleus, is uncommon. In the great majority of cases supranuclear facial
paralysis is part of a hemiplegia. Paralysis is on the same side as that of the
arm and leg because the facial muscles bear precisely the same relation to the
cortex as the spinal muscles. The nuclei of origin on either side of the middle
line in the medulla are united by decussating fibres with the cortical centre
on the opposite side (see Fig. 9). A few fibres reach the nucleus from the
cerebral cortex of the same side (Melius, Hoche), and this uncrossed path
may innervate the upper facial muscles (Bruce).
2. The nuclear paralysis caused by lesions of the nerve-centres in the
medulla is not common alone ; but is seen occasionally in tumors, chronic soft-
ening, and haemorrhage. We have had one instance of its involvement in
anterior polio-myelitis. In diphtheria this centre may also be involved. The
symptoms are practically similar to those of an affection of the nerve fibre
itself — infranuclear paralysis.
3. Involvement of the Nerve Trunk. — Paralysis may result from :
{a) Involvement of the nerve as it passes through the pons — that is, be-
tween its nucleus in the floor of the fourth ventricle and the point of emer-
gence in the postero-lateral aspect of the pons. The specially interesting
feature in connection with involvement of this part is the production of what
is called alternating or crossed paralysis, the face being involved on the same
side as the lesion, and the arm and leg on the opposite side, since the motor
path is involved above the point of decussation in the medulla ( Fig. 9 ) . This
occurs only when the lesion is in the lower section of the pons. A lesion in
the upper half of the pons involves the fibres not of the outgoing nerve on the
same side, but of the fibres from the hemispheres before they have crossed to
the nucleus of the opposite side. In this case there would of course be, as
in hemiplegia, paralysis of the face and limbs on the side opposite to the
lesion. The palsy, too, would resemble the cerebral form, involving only the
lower fibres of the facial nerve.
(&) The nerve may be involved at its point of emergence by tumors, par-
ticularly by the cerebello-pontine growths, by gummata, meningitis, or occa-
sionally it may be injured in fracture of the base.
1020 DISEASES OF THE NERVOUS SYSTEM.
(c) In passing through the Fallopian canal the nerve may be involved
in disease of the ear. particularly by caries of the bone in otitis media. This
is a common cause in children. I have seen two instances follow otitis in
puerperal fever.
(d) As the nerve emerges from the styloid foramen it is exposed to in-
juries and blows which not infrequently cause paralysis. The fibres may be
cut in the removal of tumors in this region, or the parah'sis may be caused by
pressure of the forceps in an instrumental delivery.
(e) Exposure to cold is the most common cause of facial paralysis (Bell's
palsy), inducing a neuritis of the nerve within the Fallopian canal.
(f) Syphilis is not an infrequent cause, and the paralysis may appear
early with the secondary s^maptoms.
(g) It may occur in association with herpes.
Facial diplegia is a rare condition occasionally found in affections at the
base of the brain, lesions in the pons, simultaneous involvement of the nerves
in ear-disease, and in diphtheritic paralysis. Disease of the nuclei or sym-
metrical involvement of the cortex might also produce it. It may occur as
a congenital affection. H. M. Thomas has described two cases in one family.
Symptoms. — In the peripheral facial paralysis all the branches of the
nerve are involved. The face on the affected side is immobile and can neither
be moved at vrill nor participate in any emotional movements. The skin is
smooth and the wrinkles are effaced, a point particularly noticeable on the
forehead of elderly persons. The eye can not be closed, the lower lid droops,
and the eye waters. On the affected side the angle of the mouth is lowered,
and in drinking the lips are not kept in close apposition to the glass, so that
the liqnid is apt to run out. In smiling or laughing the contrast is most
striking, as the affected side does not move, which gives a curious unequal
appearance to the two sides of the face. The eye can not be closed nor can
the forehead be T\Tinkled. In long-standing cases, when the reaction of
degeneration is present, if the patient tries to close the eyes while looking
fixedly at an object the lids on the sound side close firmly, but on the paralyzed
side there is only a slight inhibitory droop of the upper lid, and the eye is
turned upward and outward by the inferior oblique. On asking the patient
to show his upper teeth, the angle of the mouth is not raised. In all these
movements the face is drawn to the sound side by the action of the muscles.
Speaking may be slightly interfered vtdth, owing to the imperfection in the
formation of the labial sounds. Whistling can not be performed. In chew-
ing the food, owing to the paralysis of the buccinator, particles collect on the
affected side. The paralysis of the nasal muscles is seen on asking the patient
to sniff. Owing to the fact that the lips are drawn to the sound side, the
tongue, when protruded, looks as if it were pushed to the paralyzed side ; but
on taking its position from the incisor teeth, it will be found to be in the mid-
dle line. The reflex movements are lost in this peripheral form. It is usually
stated that the palate is partially paralyzed on the same side and that the
u^^lla deviates. Both Gowers and Hughlings Jackson deny the existence of
this involvement in the great majority of cases, and Horsley and Beevor have
shown that these parts are innervated by the accessory nerve to the vagus.
When the nerve is involved within the canal between the genu and the;
origin of the chorda t^Tiipani, the sense of taste is lost in the anterior part of
DISEASES OF THE PERIPHERAL NERVES. 1021
the tongue on the affected side. When the nerve is damaged outside the skull
the sense of taste is unaffected. Hearing is often impaired in facial paralysis,
most commonly by preceding ear-disease. The paralysis of the stapedius
muscle may lead to increased sensitiveness to musical notes. Herpes is some-
times associated with facial paralysis. Pain is not common, but there may
be neuralgia about the ear. The face on the affected side may be swollen.
The electrical reactions, which are those of a peripheral palsy, have con-
siderable importance from a prognostic standpoint. Erb's rules are as fol-
lows : If there is no change, either f aradic or galvanic, the prognosis is good
and recovery takes place in from fourteen to twenty days. If the faradic
and galvanic excitability of the nerve is only lessened and that of the muscle
increased to the galvanic current and the contraction formula altered (the
contraction sluggish AC>KC), the outlook is relatively good and recovery
will probably take place in from four to six weeks ; occasionally in from eight
to ten. When the reaction of degeneration is present — that is, if the faradic
and galvanic excitability of the nerves and the faradic excitability of the mus-
cles are lost and the galvanic excitability of the muscle is quantitatively in-
creased and qualitatively changed, and if the mechanical excitability is altered
— the prognosis is relatively unfavorable and the recovery may not occur for
two, six, eight, or even fifteen months.
CouESE. — The course of facial paralysis is usually favorable. The onset
in the form following cold is very rapid, developing perhaps within twenty-
four hours, but rarely is the paralysis permanent. Eecurring attacks have
been described; Sinkler mentions five. On the other hand, in the paralysis
from injury, as by a blow on the mastoid process, the condition may remain.
When permanent, the muscles are entirely toneless. In some instances con-
tracture develops as the voluntary power returns, and the natural folds and the
wrinkles on the affected side may be deepened, so that on looking at the face
one at first may have the impression that the affected side is the sound one.
This is corrected at once on asking the patient to smile, when it is seen which
side of the face has the most active movement. Aretseus noted the difficulty
sometimes experienced in determining which side was affected until the patient
spoke or laughed.
The diagnosis of facial paralysis is usually easy. The distinction between
the peripheral and central form is based on facts already mentioned.
Teeatment. — In the cases which result from cold and are probably due
to neuritis within the bony canal, hot applications first should be made; sub-
sequently the thermo-cautery may be used lightly at intervals of a day or two
over the mastoid process, or small blisters applied. If the ear is diseased,
free discharge for the secretion should be obtained. The galvanic current may
be employed to keep up the nutrition of the muscles. The positive pole should
be placed behind the ear, the negative one along the zygomatic and other mus-
cles. The application can be made daily for a quarter of an hour and the
patient can readily be taught to make it himself before the looking-glass.
Massage of the muscles of the face is also useful. A course of iodide of potas-
sium may be given even when there is no indication of syphilis.
In those cases in which the nerve has been destroyed by an injury, during
an operation or from disease, and when there has been no evidence of return-
ing function after keeping up the electric treatment for a few months, a nerve
1022 DISEASES OF THE NERVOUS SYSTEM.
anastomosis should be performed. For this purpose either the spinal acces-
sory or the hypoglossal nerve may be used. Though the normal conditions
may never be completely regained after such an operation, the motor power
will be largely restored to the paralyzed muscles and the obtrusive deformity
greatly lessened. This procedure, based on the results of physiological experi-
mentation, makes one of the most striking of modern operations.
Spasm. — The spasm may be limited to a few or involve all the muscles
innervated by the facial nerve, and may be unilateral or bilateral.
It is known also by the name of mimic spasm or of convulsive tic. Sev-
eral different affections are usually considered under the name of facial or
mimic spasm, but we shall here speak only of the simple spasm of the facial
muscles, either primary or following paralysis, and shall not include the cases
of habit spasm in children, or the tic convulsif of the French.
Gowers recognizes two classes — one in which there is an organic lesion,
and an idiopathic form. It is thought to be due also to reflex causes, such
as the irritation from carious teeth or the presence of intestinal worms. The
disease usually occurs in adults, whereas the habit spasm and the tic convulsif
of the French, often confounded with it, are most common in children. True
mimic spasm occasionally comes on in childhood and persists. In the case of
a school-mate, the affection was marked as early as the eleventh or twelfth year
and still continues. When the result of organic disease, there has usually been
a lesion of the centre in the cortex, as in the case reported by Berkley, or
pressure on the nerve at the base of the brain by aneurism or tumor.
Symptoms. — The spasm may involve only the muscles around the eye —
blepharospasm — in which case there is constant, rapid, quick action of the
orbicularis palpebrarum, which, in association with photophobia, may be tonic
in character. More commonly the spasm affects the lateral facial muscles with
those of the eye, and there is constant twitching of the side of the face with
partial closure of the eye. The frontalis is rarely involved. In aggravated
cases the depressors of the angle of the mouth, the levator menti, and the
platysma myoides are affected. This spasm is confined to one side of the face
in a majority of cases, though it may extend and become bilateral. It is
increased by emotional causes and by voluntary movements of the face. As
a rule, it is painless, but there may be tender points over the course of the fifth
nerve, particularly the supraorbital branch. Tonic spasm of the facial mus-
cle may follow paralysis, and is said to result occasionally from cold.
The outlook in facial spasm is always dubious. A majority of the cases
persist for years and are incurable.
Treatment. — Sources of irritation should be looked for and removed.
When a painful spot is present over the fifth nerve, blistering or the appli-
cation of the thermo-cautery may relieve it. Hypodermic injections of strych-
nia may be tried, but are of doubtful benefit. Weir Mitchell recommends the
freezing of the cheek for a few minutes daily or every second day with the
spray, and this, in some instances, is beneficial. Often the relief is transient ;
the cases return, and at every clinic may be seen half a dozen or more of such
patients who have run the gamut of all measures without material improve-
ment. Severe cases may require surgical interference. The nerve may be
divided near the stylomastoid foramen and an anastomosis made between it
and the spinal accessory.
DISEASES OF THE PERIPHERAL NERVES. 1023
Auditory Nerve.
The eighth, known also as portio mollis of the seventh pair, passes from
the ear through the internal auditory meatus, and in reality consists of two
separate nerves — the cochlear and vestibular roots. These two roots have en-
tirely different functions, and may therefore be best considered separately.
The cochlear nerve is the one connected with the organ of Corti, and is con-
cerned in hearing. The vestibular nerve is connected with the vestibule and
semicircular canals, and has to do with the maintenance of equilibrium.
The Cochlear Nerve.
The cortical centre for hearing is in the temporo-sphenoidal lobe. Primary
disease of the auditory nerve in its centre or intracranial course is uncommon.
More frequently the terminal branches are affected within the labyrinth.
(a) Affection of the Cortical Centre. — In the monkey, experiments indi-
cate that the superior temporal gyrus represents the centre for hearing. In
man the cases of disease indicate that it has the same situation, as destruction
of this gyrus on the left side results in word-deafness, which may be defined
as an inability to understand the meaning of words, though they may still
be heard as sounds. The central auditory path extending to the cortical centre
from the terminal nuclei of the cochlear nerve may be involved and produce
deafness. This may result from involvement of the lateral lemniscus, from
the presence of a tumor in the corpora quadrigemina, especially if it involve
the posterior quadrigeminal bodies, from a lesion of the internal geniculate
body, or it may be associated with a lesion of the internal capsule.
(&) Lesions of the nerve at the base of the brain may result from the
pressure of tumors, meningitis (particularly the cerebro-spinal form), haem-
orrhage, or traumatism. A primary degeneration of the nerve may occur in
locomotor ataxia. Primary disease of the terminal nuclei of the cochlear nerve
(nucleus nervi cochlearis dorsalis and nucleus nervi cochlearis ventralis) is
rare. By far the most interesting form results from epidemic cerebro-spinal
meningitis, in which the nerve is frequently involved, causing permanent
deafness. In young children the condition results in deaf-mutism.
(c) In a majority of the cases associated with auditory-nerve symptoms
the lesion is in the internal ear, either primary or the result of extension of
disease of the middle ear. Two groups of symptoms may be produced — hyper-
sesthesia and irritation, and diminished function or nervous deafness.
(1) Hypercesthesia and Irritation. — This may be due to altered function
of the centre as well as of the nerve ending. True hypersesthesia — hyperacusis
— is a condition in which sounds, sometimes even those inaudible to other
persons, are heard with great intensity. It occurs in hysteria and occasionally
in cerebral disease. As already mentioned, in paralysis of the stapedius low
notes may be heard with intensity. In dysgesthesia, or dysacusis, ordinary
sounds cause an unpleasant sensation, as commonly happens in connection
with headache, when ordinary noises are badly borne.
Tinnitus aurium is a term employed to designate certain subjective sensa-
tions of ringing, roaring, tickling, and whirring noises in the ear. It is a
very common and often a distressing symptom. It is associated with many
1024 DISEASES OF THE NERVOUS SYSTEM.
forms of ear-disease and may result from pressure of wax on the drum. It is
rare in organic disease of the central connections of the nerve. Sudden in-
tense stimulation of the nerve may cause it. A form not uncommonly met
with in medical practice is that in which the patient hears a continual bruit
in the ear, and the noise has a systolic intensification, usually on one side. I
have twice been consulted by physicians for this condition under the belief
that they had an internal aneurism, A systolic murmur may be heard occa-
sionally on auscultation. It occurs in conditions of anemia and neurasthenia.
Subjective noises in the ear may precede an epileptic seizure and are sometimes
present in migraine. In whatever form tinnitus exists, though slight and
often regarded as trivial, it occasions great annoyance and often mental dis-
tress, and has even driven patients to suicide.
The diagnosis is readily made; but it is often extremely difficult to deter-
mine upon what condition the tinnitus depends. The relief of constitutional
states, such as anaemia, neurasthenia, or gout, may result in cure. A careful
local examination of the ear should always be made. One of the most worry-
ing forms is the constant clicking, sometimes audible many feet away from
the patient, and due probably to clonic spasm of the muscles connected with
the Eustachian tube or of the levator palati. The condition may persist for
years unchanged, and then disappear suddenly. The pulsating forms of tinni-
tus, in which the sound is like that of a systolic hruit, are almost invariably
subjective, and it is very rare to hear anything with the stethoscope. It is
to be remembered that in children there is a systolic brain murmur, best
heard over the ear, and in some instances appreciable in the adult.
(2) Diminished Function or Nervous Deafness. — In testing for nervous
deafness, if the tuning-fork can not be heard when placed near the meatus,
but the vibrations are audible by placing the foot of the tuning-fork against
the temporal bone, the conclusion may be drawn that the deafness is not due
to involvement of the nerve. The vibrations are conveyed through the tem-
poral bone to the cochlea and vestibule. The watch may be used for the same
purpose, and if the meatus is closed and the watch is heard better in contact
with the mastoid process than when opposite the open meatus, the deafness
is probably not nervous. Disturbance of the function of the auditory nerve
is not a very frequent s}miptom in brain-disease, but in all cases the function
of the nerve should be carefully tested.
The Vestibular Nerve.
The most frequent s}T2iptoms met with in association with disease of the
vestibular nerve and its central connections are vertigo, nystagmus, and loss
of coordination of the muscles of the head, neck, and eyes.
Auditory Vertigo — Meniere's Disease, — In 1861 Meniere, a French phy-
sician, described an affection characterized by noises in the ear, vertigo (which
might be associated with loss of consciousness), vomiting, and, in many cases,
progressive loss of hearing. The following grouping of the cases has been
made by Parkes Weber: (1) The apoplectic form, due to hgemorrhage into the
labyrinth, as in leukaemia, followed, as a rule, by complete deafness in one
or both ears. (2) The cases associated with progressive inflammatory disease
of the labyrinth. (3) Associated with organic changes in the auditory nerves,
DISEASES OF THE PERIPHERAL NERVES. 1025
as in tumors, sometimes in tabes, and in cases of aural vertigo associated with
facial paralysis on one side. (4) Cases in which a paroxysm of epilepsy is
preceded by an auditory aura. (5) The moderate attacks which are associated
with the various middle-ear affections, with wax in the meatus, with violent
syringing of the ears, etc., all of which are probably due to increase in the
intra-labyrinthine pressure. Meniere's symptoms may occasionally be due to
temporary excessive increase in the perilymph, possibly of angioneurotic
character.
Symptoms. — The attack usually sets in suddenly with a buzzing noise in
the ears and the patient feels as if he was reeling or staggering. He may feel
himself to be reeling, or the objects about him may seem to be turning, or the
phenomena may be combined. The attack is often so abrupt that the patient
falls, though, as a rule, he has time to steady himself by grasping some neigh-
boring object. There may be slight but transient loss of consciousness. In a
few minutes, or even less, the vertigo passes off and the patient becomes pale
and nauseated, a clammy sweat breaks out on the face, and vomiting may
follow.
The tinnitus is described as either a roaring or a throbbing sound. Ocular
symptoms may be present; thus, jerking of the eyeballs or nystagmus may
develop during the attack, or diplopia.
Labyrinthine vertigo is paroxysmal, coming on at irregular intervals, some-
times of weeks or months; or several attacks may occur in a day.
The disturbances of equilibrium, including the vertigo, are dependent upon
a disturbance of the functions of the vestibular nerve or of the organs with
which this nerve is connected, either in its peripheral distribution or by means
of its central connection. The auditory symptoms often accompanying it are
doubtless always due to involvement of the cochlear nerve or its peripheral
or central connections.
Diagnosis. — The combination of tinnitus with giddiness, with or without
gastric disturbance, is sufficient to establish a diagnosis. There are other
forms of vertigo from which it must be distinguished. The form known as
gastric vertigo, which is associated with dyspepsia and occurs most commonly
in persons of middle age, is, as a rule, readily distinguished by the absence
of tinnitus or evidences of disturbance in the function of the auditory nerve.
This variety of vertigo is much less common than Trousseau's description
would lead us to believe. It is important to note the close connection of vertigo
with ocular defects.
The cardio-vascular vertigo, one of the most common forms, occurs in
cases of valvular disease, particularly aortic insufficiency, and as frequently
in arterio-sclerosis.
Endemic Paralytic Vertigo. — In parts of Switzerland and France there is
a remarkable form of vertigo described by Gerlier, which is characterized by
attacks of paretic weakness of the extremities, falling of the eyelids, remarkable
depression, but with retention of consciousness. It occurs also in northern
Japan, where Miura says it develops paroxysmally among the farm laborers
of both sexes and all ages. It is known there as Jcuhisagari.
Aural vertigo must be carefully distinguished from attacks of petit mal,
or, indeed, of definite epilepsy. It is rare in petit mal to have noises in the
ear or actual giddiness, but in the aura preceding an epileptic attack the
1026 DISEASES OF THE NERVOUS SYSTEM.
patient may feel giddy. Giddiness and transient loss of consciousness may
be associated with organic disease of the brain, more particularly with tumor.
Vomiting also may be present. A careful investigation of the symptoms will
usually lead to a correct diagnosis.
The outlook in Meniere^s disease is uncertain. While many cases recover
completely, in others deafness results and the attacks recur at shorter inter-
vals. In aggravated cases the patient constantly suffers from vertigo, and
may even be confined to his bed.
Teeatment. — Bromide of potassium, in 30-grain doses three times a day,
is sometimes beneficial. If there is a history of syphilis, the iodide should be
administered. The salicylates are recommended, and Charcot advises quinine
to einchonism. In cases in which there is increase in the aisrterial tension,
nitroglycerin may be given, at first in very small doses, but increasing gradu-
ally. It is not specially valuable in Meniere's disease, but in the cases of
giddiness in middle-aged men and women associated with arterio-sclerosis it
sometimes acts very satisfactorily. Correction of errors of refraction is some-
times followed by prompt relief of the vertigo.
Glosso-phaeyngeal Neeve (Nervus glossopliaryngeus).
The ninth nerve contains both motor and sensory fibres and is also a nerve
of the special sense of taste to the tongue. It supplies, by its motor branches,
the stylo-pharyngeus and the middle constrictor of the pharynx. The sensory
fibres are distributed to the upper part of the pharynx.
Symptoms. — Of nuclear disturbance we know very little. The pharyngeal
symptoms of bulbar paralysis are probably associated with involvement of the
nuclei of this nerve. Lesion of the nerve trunk itself is rare, but it may be
compressed by tumors or involved in meningitis. Disturbance of the sense of
taste may result from loss of function of this nerve, in which case it is chiefly
in the posterior part of the tongue and soft palate.
The general disturbances of the sense of taste may here be briefly referred
to. Loss of the sense of taste — ageusia — may be caused by disturbance of the
peripheral end organs, as in affections of the mucosa of the tongue. This is
very common in the dry tongue of fever or the furred tongue of dyspepsia,
under which circumstances, as the saying is, everything tastes alike. Strong
irritants, too, such as pepper, tobacco, or vinegar, may dull or diminish the
sense of taste. Complete loss may be due to involvement of the nerves either
in their course or in the centres. Perversion of the sense of taste — parageusis
— is rarely found, except as an hysterical manifestation and in the insane.
Increased sensitiveness is still more rare. There are occasional subjective
sensations of taste, occurring as an aura in epilepsy or as part of the hallu-
cinations in the insane.
To test the sense of taste the patient's eyes should be closed and small
quantities of various substances applied to the protruded tongue. The sensa-
tion should be perceived before the tongue is withdrawn. The following are
the most suitable tests : For bitterness, quinine ; for sweetness, a strong solution
of sugar or saccharin; for acidity, vinegar; and for the saline test, common
salt. One of the most important tests is the feeble galvanic current, which
gives the well-known metallic taste.
DISEASES OF THE PERIPHERAL NERVES. 1027
Pneumogasteic Nerve {Nervus vagus).
The tenth nerve has an important and extensive distribution, supplying
the pharynx, larynx, lungs, heart, oesophagus, and stomach. The nerve may
be involved at its nucleus along with the spinal accessory and the hypoglossal,
forming what is known as bulbar paralysis. It may be compressed by tumors
or aneurism, or in the exudation of meningitis, simple or syphilitic. In its
course in the neck the trunk may be involved by tumors or in wounds. It has
been tied in ligature of the carotid, and has been cut in the removal of deep-
seated tumors. The trunk may be attacked by neuritis.
The affections of the vagus are best considered in connection with the
distribution of the separate nerves.
(a) Pharyngeal Branches. — In combination with the glosso-pharyngeal the
branches from the vagus form the pharyngeal plexus, from which the muscles
and mucosa of the pharynx are supplied. In paralysis due to involvement of
this either in the nuclei, as in bulbar paralysis, or in the course of the nerve,
as in diphtheritic neuritis, there is difficulty in swallowing and the food is not
passed on into the oesophagus. If the nerve on one side only is involved, the
deglutition is not much impaired. In these cases the particles of food fre-
quently pass into the larynx, and, when the soft palate is involved, into the
posterior nares.
Spasm of the pharynx is always a functional disorder, usually occurring
in hysterical and nervous people. Growers mentions a case of a gentleman
who could not eat unless alone, on account of the inability to swallow in the
presence of others from spasm of the pharynx. This spasm is a well-marked
feature in hydrophobia, and I have seen it in a case of pseudo-hydrophobia.
(&) Laryngeal Branches. — The superior laryngeal nerve supplies the mu-
cous membrane of the larynx above the cords and the crico-thyroid muscle.
The inferior or recurrent laryngeal curves around the arch of the aorta on
the left side and the subclavian artery on the right, passes along the trachea
and supplies the mucosa below the cords and all the muscles of the larynx
except the crico-thyroid and the epiglottidean. Experiments have shown that
these motor nerves of the pneumogastric are all derived from the spinal
accessory. The remarkable course of the recurrent laryngeal nerves renders
them liable to pressure by tumors within the thorax, particularly by aneurism.
The following are the most important forms of paralysis :
(1) Bilateral Paralysis of the Abductors. — In this condition, the
posterior crico-arytenoids are involved and the glottis is not opened during
inspiration. The cords may be close together in the position of phonation,
and during inspiration may be brought even nearer together by the pressure
of air, so that there is only a narrow chink through which the air whistles
with a noisy stridor. This dangerous form of laryngeal paralysis occurs occa-
sionally as a result of cold, or may follow a laryngeal catarrh. The posterior-
muscles have been found degenerated when the others were healthy. The con-
dition may be produced by pressure upon both vagi, or upon both recurrent
nerves. As a central affection it occurs in tabes and bulbar paralysis, but may
be seen also in hysteria. The characteristic symptoms are inspiratory stridor
with unimpaired phonation. Possibly, as Gowers suggests, many cases of
so-called hysterical spasm of the glottis are in reality abductor paralysis.
1028
DISEASES OF THE NERVOUS SYSTEM.
(2) Unilateral Abductor Paralysis. — This frequently results from the
pressure of tumors or involvement of one recurrent nerve. Aneurism is by
far the most common cause, though on the right side the nerve may be involved
in thickening of the pleura. The symptoms are hoarseness or roughness of
the voice, such as is so common in aneurism. Dyspnoea is not often present.
The cord on the affected side does not move in inspiration. Subsequently the
adductors may also become involved, in which case the phonation is still more
impaired.
(3) Adductor Paralysis. — This results from involvement of the lateral
crico-arytenoid and the arytenoid muscle itself. It is common in hysteria,
particularly of women, and causes the hysterical aphonia, which may come on
suddenly. It may result from catarrh of the larynx or from overuse of the
voice. In laryngoscopic examination it is seen, on attempting phonation, that
there is no power to bring the cords together. In this connection the following
table from Gowers' work will be found valuable to the student:
Symptoms.
No voice; no cough;
stridor only on deep in-
spiration.
Voice low pitched
and hoarse; no cough;
stridor absent or slight
on deep breathing.
Voice little changed;
cough normal ; inspira-
tion difficult and long,
with loud stridor.
Symptoms inconclu-
sive; little affection of
voice or cough.
No voice ; perfect
cough; no stridor or
dyspnoea.
Signs.
Both cords moder-
ately abducted and mo-
tionless.
One cord moderately
abducted and motionless,
the other moving freely,
and even beyond the mid-
dle line in phonation.
Both cords near to-
gether, and during in-
spiration not separated,
but even drawn nearer
together.
One cord near the
middle line not moving
during inspiration, the
other normal.
Cords normal in po-
sition and moving nor-
mally in respiration,
but not brought together
on an attempt at phona-
tion.
Lesion.
Total bilateral palsy.
Total unilateral palsy.
Total abductor palsy.
Unilateral abductor
palsy.
Adductor palsy.
Spasm of the Muscles of the Larynx. — ^In this the adductor muscles
are involved. It is not an uncommon affection in children, and has already
been referred to as lar3Tigismus stridulus. Paroxysmal attacks of laryngeal
spasm are rare in the adult, but cases are described in which the patient,
usually a young girl, wakes at night in an attack of intense dyspnoea, which
may persist long enough to produce cyanosis. Liveing states that they may
replace attacks of migraine. They occur in a characteristic form in loco-
DISEASES OF THE PERIPHERAL NERVES. 1029
motor ataxia, forming tlic so-called laryngeal crises. There is a condition
known as spastic aphonia, in which, when the patient attempts to speak, pho-
nation is completely prevented by a spasm.
Disturbance of the sensory nerves of the larynx is rare.
Anesthesia may occur in bulbar paralysis and in diphtheritic neuritis —
a serious condition, as portions of food may enter the windpipe. It is usu-
ally associated with dysphagia and is sometimes present in hysteria. Hyper-
sesthesia of the larynx is rare.
(c) Cardiac Branches. — The cardiac plexus is formed by the union of
branches of the vagi and of the sympathetic nerves. The vagus fibres sub-
serve motor, sensory, and probably trophic functions.
(1) MoTOE. — The fibres which inhibit, control, and regulate the cardiac
action pass in the vagi. Irritation may produce slowing of the action. Czer-
mak could slow or even arrest the heart's action for a few beats by pressing
a small tumor in his neck against one pneumogastric nerve, and it is said
that the same can be produced by forcible bilateral pressure on the carotid
canal. There are instances in which persons appear to have had voluntary
control over the action of the heart. Cheyne mentions the case of Colonel
Townshend, " who could die or expire when he pleased, and yet by an efEort
or somehow come to life again, which it seems he had sometimes tried before
he had sent for us." Retardation of the heart's action has also followed acci-
dental ligature of one vagus. Irritation of the nuclei may also be accom-
panied with a neurosis of this nerve. On the other hand, when there is com-
plete paralysis of the vagi, the inhibitory action may be abolished and the
acceleratory influences have full sway. The heart's action is then greatly
increased. This is seen in some instances of diphtheritic neuritis and in
involvement of the nerve by tumors, or its accidental removal or ligature.
Complete loss of function of one vagus, however, may not be followed by any
symptoms.
(3) Sensoey symptoms on the part of the cardiac branches are very varied.
Normally, the heart's action proceeds regularly without the participation of
consciousness, but the unpleasant feelings and sensations of j)alpitation and
pain are conveyed to the brain through this nerve. How far the fibres of the
pneumogastric are involved in angina it is impossible to say. The various
disturbances of sensation are described under the cardiac neuroses.
{d) Pulmonary Branches. — We know very little of the pulmonary branches
of the vagi. The motor fibres are stated to control the action of the bronchial
muscles, and it has long been held that asthma may be a neurosis of these
fibres. The various alterations in the respiratory rhythm are probably due
more to changes in the centre than in the nerves themselves.
(e) Gastric and (Esophageal Branches. — The muscular movements of these
parts are presided over by the vagi and vomiting is induced through them,
usually reflexly, but also by direct irritation, as in meningitis. Spasm of the
oesophagus generally occurs with other nervous phenomena. Gastralgia may
sometimes be due to cramp of the stomach, but is more commonly a sensory
disturbance of this nerve, due to direct irritation of the peripheral ends, or
is a neuralgia of the terminal fibres. Hunger is said to be a sensation aroused
by the pneumogastric, and some forms of nervous dyspepsia probably depend
upon disturbed function of this nerve. The severe gastric crises which occur
1030 DISEASES OF THE NERVOUS SYSTEM.
in locomotor ataxia are due to central irritation of the nuclei. Some describe
exophthalmic goitre under lesions of the vagi.
Spiistal Accessoey Neeve (Nervus accessorius) .
Paralysis. — The smaller or internal part of this nerve joins the vagus and
is distributed through it to the lar}'ngeal muscles. The larger external part
is distributed to the sterno-mastoid and trapezius muscles.
The nuclei of the nerve, particularly of the accessory part, may be in-
volved in bulbar paralysis. The nuclei of the external portion, situated as
they are in the cervical cord, may be attacked in progressive degeneration of
the motor nuclei of the cord. The nerve may be involved in the exudation of
meningitis, or be compressed by tumors, or in caries. The symptoms of paraly-
sis of the accessory portion which joins the vagus have already been given in
the account of the palsy of the larj-ngeal branches of the pneumogastric. Dis-
ease or compression of the external portion is followed b}^ paralysis of the
sterno-mastoid and of the trapezius on the same side. In paralysis of one
sterno-mastoid, the patient rotates the head with difficulty to the opposite
side, but there is no torticollis, though in some cases the head is held obliquely.
As the trapezius is supplied in part from the cervical nerves, it is not com-
pletely paralyzed, but the portion which passes from the occipital bone to the
acromion is functionless. The paralysis of the muscle is well seen when the
patient draws a deep breath or shrugs the shoulders. The middle portion of
the trapezius is also weakened, the shoulder droops a little, and the angle
of the scapula is rotated inward by the action of the rhomboids and the levator
anguli scapulse. Elevation of the arm is impaired, for the trapezius does not
fix the scapula as a point from which the deltoid can work.
In progressive muscular atroph}' we sometimes see bilateral paralysis of
these muscles. Thus, if the sterno-mastoids are affected, the head tends to
fall back; when the trapezii are involved, it falls forward, a characteristic
attitude of the head in many cases of progressive muscular atrophy. Gowers
suo-CTests that lesions of the accessorv in difficult labor mav account for those
cases in which during the first year of life the child has great difficulty in
holding up the head. In children this drooping of the head is an important
symptom in cervical meningitis, the result of caries.
The treatment of the condition depends much upon the cause. In the
central nuclear atrophy but little can be done. In paralysis from pressure
the symptoms may gradually be relieved. The paralyzed muscles should be
stimulated by electricity and massage.
Accessory Spasm. — (Toeticollis; Wryn^eck.) — The forms of spasm
affecting the cervical muscles are best considered here, as the muscles supplied
by the accessory are chiefly, though not solely, responsible for the condition.
The following forms may be described in this section :
(a) Congenital Toeticollis. — This condition, also known as fixed torti-
collis, depends upon the shortening and atrophy of the sterno-mastoid on
one side. It occurs in children and may not be noticed for several years on
account of the shortness of the neck, the parents often alleging that it has
only recently come on. It affects the right side almost exclusively. A re-
markable circumstance in connection with it is the existence of facial asym-
DISEASES OF THE PERIPHERAL NERVES, 1031
metry noted by Wilks, which appears to be an essential part of this congenital
form. It occurred in 6 cases reported by Golding-Bird. In congenital wry-
neck the sterno-mastoid is shortened, hard and firm, and in a condition of
more or less advanced atrophy. This must be distinguished from the local
thickening in the sterno-mastoid due to rupture, which may occur at the time
of birth and produce an induration or muscle callus. Although the sterno-
mastoid is almost always affected, there are rare cases in which the fibrous
atrophy affects the trapezius. This form of wryneck in itself is unimportant,
since it is readily relieved by tenotomy, but Golding-Bird states that the facial
asymmetry persists, or indeed may, as shown by photographs in my case, be-
come more evident. With reference to the pathology of the affection, Golding-
Bird concludes that the facial asymmetry and the torticollis are integral parts
of one affection which has a central origin, and is the counterpart in the head
and neck of infantile paralysis with talipes in the foot.
(b) Spasmodic Weyneck. — Two varieties of this spasm occur, the tonic
and the clonic, which may alternate in the same case ; or, as is most common,
they are separate and remain so from the outset. The disease is most frequent
in adults and, according to Gowers, more common in females. In America
it is certainly more frequent in males. Of the 8 or 10 cases which came
under my observation in Montreal and Philadelphia, all were males. In
females it may be an hysterical manifestation. There may be a marked neu-
rotic family history, but it is usually impossible to fix upon any definite etio-
logical factor. Some cases have followed cold; others a blow. Brissaud has
described what he calls mental torticollis. It is usually met with in neuras-
thenic patients and in elderly persons, and consists of a clonic spasm of the
rotators of the head.
The symptoms are well defined. In the tonic form the contracted sterno-
mastoid draws the occiput toward the shoulder of the affected side; the chin
is raised, and the face rotated to the other shoulder. The sterno-mastoid may
be affected alone or in association with the trapezius. When the latter is
implicated the head is depressed still more toward the same side. In long-
standing cases these muscles are prominent and very rigid. There may be
some curvature of the spine, the convexity of which is toward the sound side.
The cases in which the spasm is clonic are much more distressing and serious.
The spasm is rarely limited to a single muscle. The sterno-mastoid is almost
always involved and rotates the head so as to approximate the mastoid proc-
ess to the inner end of the clavicle, turning the face to the opposite side and
raising the chin. When with this the trapezius is affected, the depression of
the head toward the same side is more marked. The head is drawn somewhat
backward ; the shoulder, too, is raised by its action. According to Gowers, the
splenius is associated with the sterno-mastoid about half as frequently as the
trapezius. Its action is to incline the head and rotate it slightly toward
the same side. Other muscles may be involved, such as the scalenus and
platysma myoides ; and in rare cases the head may be rotated by the deep cervi-
cal muscles, the rectus and obliquus. There are cases in which the spasm is
bilateral, causing a backward movement — the retro-collic spasm. This may
be either tonic or clonic, and in extreme cases the face is horizontal and looks
upward.
These clonic contractions may come on without warning, or be preceded
1032 DISEASES OF THE NERVOUS SYSTEM.
for a time by irregular pains or stiffness of the neck. The jerking movements
recur every few moments, and it is impossible to keep the head still for more
than a minute or two. In time the muscles undergo hj^Dertrophy and may be
distinctly larger on one side than the other. In some cases the pain is consid-
erable ; in others there is simply a feeling of fatigue. The spasms cease dur-
ing sleep. Emotion, excitement, and fatigue increase them. The spasm may
extend from the muscles of the neck and involve those of the face or of the
arms.
The disease varies much in its course. Cases occasionally get well, but
the great majority of them persist, and, even if temporarily relieved, the
disease frequently recurs. The affection is usually regarded as a functional
neurosis, but it is possibly due to disturbance of the cortical centres presiding
over the muscles.
Treatment. — Temporary relief is sometimes obtained; a permanent cure
is exceptional. Various drugs have been used, but rarely with benefit. Occa-
sionally, large doses of bromide will lessen the intensity of the spasm. Mor-
phia, subcutaneousl}', has been successful in some reported cases, but there
is the great danger of establishing the morphia habit. Galvanism may be
tried. Counter-irritation is probably useless. Fixation of the head mechan-
ically can rarely be borne by the patient. These obstinate cases fall ultimately
into the hands of the surgeon, and the operations of stretching, division, and
excision of the accessory nerve and division of the muscles have been tried.
Temporary relief may follow, but, as a rule, the condition returns. Risien
Eussell thinks that resection of the posterior branches of the upper cervical
nerves is most likely to give relief, and this has been done by Keen and
others.
(c) The XODDIXG SPASM of children may here be mentioned as involving
chiefly the muscles innervated by the accessory nerve. It may be a simple trick,
a form of habit spasm, or a phenomenon of epilepsy (E. nutans), in which
case it is -associated with transient loss of consciousness. A similar nodding
spasm may occur in older children. In women it sometimes occurs as an hys-
terical manifestation, commonly as part of the so-called salaam convulsion.
Hypoglossal Nerve.
This is the motor nerve of the tongue and for most of the muscles attached
to the hyoid bone. Its cortical centre is probably the lower part of the ante-
rior central gyrus.
Paralysis. — (1) Cortical Lesion. — The tongue is often involved in hemi-
plegia, and the paralysis may result from a lesion of the cortex itself, or of
the fibres as they pass to the medulla. It does not occur alone and is consid-
ered with hemiplegia. There is this difference, however, between the cortical
and other forms, that the muscles on both sides of the tongue may be more or
less affected but do not waste, nor are their electrical reactions disturbed.
(3) ISTucLEAR and infra-xuclear lesions of the h3^poglossal result from
slow progressive degeneration, as in bulbar paralysis or in locomotor ataxia;
occasionally there is acute softening from obstruction of the vessels. The
nuclei of both nerves are usually affected together, but may be attacked sepa-
rately. Trauma and lead poisoning have also been assigned as causes. The
DISEASES OF THE PERIPHERAL NERVES. 1033
fibres may be damaged by a tumor, and at the base by meningitis ; or the nerve
is sometimes involved in the condylar foramen by disease of the skull. It may
be involved in its course in a scar, as in Birkett's case, or compressed by a
tumor in the parotid region. As a result, there is loss of function in the
nerve fibres and the tongue undergoes atrophy on the affected side. It is
protruded toward the paralyzed side and may show fibrillary twitching.
The symptoms of involvement of one hypoglossal, either at its centre or in
its course, are those of unilateral paralysis and atrophy of the tongue. When
protruded, it is pushed toward the affected side, and there are fibrillary twitch-
ings. The atrophy is usually marked and the mucous membrane on the affected
side is thrown into folds. Articulation is not much impaired in the unilateral
affection. There is a remarkable triad of symptoms, to which Hughlings
Jackson first called attention — unilateral hemi-atrophy of the tongue, loss of
power in the palate muscle, with paralysis of the larynx on the same side.
When the disease is bilateral, the tongue lies almost motionless in the floor
of the mouth; it is atrophied, and can not be protruded. Speech and masti-
cation are extremely difficult and deglutition may be impaired. If the seat of
the disease is above the nuclei, there may be little or no wasting. The condi-
tion is seen in progressive bulbar paralysis and occasionally in progressive mus-
cular atrophy.
The diagnosis is readily made and the situation of the lesion can usually
be determined, since when supra-nuclear there is associated hemiplegia and
no wasting of the muscles of the tongue. Nuclear disease is only occasionally
unilateral ; most commonly bilateral and part of a bulbar paralysis. It should
be borne in mind that the fibres of the hypoglossal may be involved within the
medulla after leaving their nuclei. In such a case there may be paralysis of
the tongue on one side and paralysis of the limbs on the opposite side, and the
tongue, when protruded, is pushed toward the sound side.
Spasm. — This rare affection may be unilateral or bilateral. It is most fre-
quently a part of some other convulsive disorder, such as epileps}'^, chorea, or
spasm of the facial muscles. In some cases of stuttering, spasm of the tongue
precedes the explosive utterance of the words. It may occur in hysteria, and
is said to follow reflex irritation in the fifth nerve. The most remarkable cases
are those of paroxysmal clonic spasm, in which the tongue is rapidly thrust in
and out, as many as forty or fifty times a minute. In the case reported by
Gowers the attacks occurred during sleep and continued for a year and a half.
The spasm is usually bilateral. Wendt has reported a case in which it was
unilateral. The prognosis is usually good.
IV. DISEASES OF THE SPINAL NERVES.
Cervical Plexus.
(1) Occipito-cervical Neuralgia. — This involves the nerve territory sup-
plied by the occipitalis major and minor, and the auricularis magnus nerves.
The pains are chiefly in the back of the head and neck and in the ear. The
condition may follow cold and is sometimes associated with stiffness of the
neck or torticollis. Unless connected with it there exists disease of the bones
or unless it is due to pressure of tumors, the outlook is usually good. There
67
1034 DISEASES OF THE NERVOUS SYSTEM.
are tender points mid"vray between the mastoid process and the spine and just
above the parietal eminence, and between the stemo-niastoid and the trapezius.
The affection may be due to direct pressure in carr}'ing heavy weights.
(2) Pressure of Cervical Ribs. — It is remarkable how common is this
anomaly, and the X-rays have shown that a series of cases of (a) wasting
of one arm. particularly of the small muscles of the hands, occurring some-
times in families, [h) neuralgic and pargesthetic conditions, and (c) local
spasms of the muscles of the hand, are due to the pressure of a cervical rib on
the nerves. The diagnosis is readily made and prompt relief follows removal
of the rib.
(3) Affections of tlie Phrenic Nerve. — Paralysis may follow a lesion in
the anterior horns at the level of the third and fourth cervical nerves, or may
be due to compression of the nerve by tumors or aneurism. More rarely
paralysis results from neuritis, dijihtheritic or saturnine.
Wlien the diaplrragm is paralyzed respiration is carried on by the intercos-
tal and accessory muscles. "Wlien the patient is quiet and at rest little may be
noticed, but the abdomen retracts in inspiration and is forced out in expiration.
On exertion or even on attempting to move there may be dyspnoea. If the
paralysis sets in suddenl}- there may be dj'spnoea and lividity, which is usually
temporary (W. Pasteur). Intercurrent attacks of bronchitis seriously aggra-
vate the condition. Difficulty in coughing, owing to the impossibility of
drawing a full breath, adds greatly to the danger of this complication.
When the phrenic nerve is paralyzed on one side the paralysis may be
scarcely noticeable, but careful inspection shows that the descent of the dia-
plrragm is much less on the affected side.
The diagnosis of paralysis is not always easy, particularly in women, who
habitually use this muscle less than men, and in whom the diaphragmatic
breathing is less conspicuous. Immobility of the diaphragm is not uncommon,
particularly in diaphragmatic pleurisy, in large effusions, and in extensive
emphysema. The muscle itself may be degenerated and its power impaired.
Owing to the lessened action of the diaphragm, there is a tendency to
accumulation of blood at the bases of the lungs, and there may be impaired
resonance and signs of oedema. As a rule, however, the paralysis is not con-
fined to this muscle, but is part of a general neuritis or an anterior polio-
myelitis, and there are other s}Tn23toms of value in determining its presence.
The outlook is usually serious. Pasteur states that of 15 cases following diph-
theria, only 8 recovered. The treatment is that of the neuritis or polio-mj^elitis.
Hiccoug"li. — Here may, perhaps, best be considered this remarkable s}Tnp-
tom, caused by intermittent, sudden contraction of the diaphragm. The mech-
anism, however, is complex, and while the afferent impressions to the respira-
tory centre may be peripheral or central, the efferent are distributed through the
phrenic nerve to the diaphragm, causing the intermittent spasm, and through
the laryngeal branches of the vagus to the glottis, causing sudden closure as
the air is rapidly inspired. W. Langf ord S}'mes groups the cases into :
(a) IxFLAMMATOEY, Seen particularly in affections of the abdominal vis-
cera, gastritis, peritonitis, hernia, internal strangulation, appendicitis, suppu-
rative pancreatitis, and in the severe forms of t}'phoid fever.
(&) Iekitative, as in the direct stimulation of the diaphragm when very
hot substances are swallowed, in disease of the cesophagus near the diaphragm,
DISEASES OF THE PERIPHERAL NERVES. 1035
and in many conditions of gastric and intestinal disorder, more particularly
those associated with flatus.
(c) Specific^ or, perhaps more properly, idiopathic, in which no evi-
dent causes are present. In these cases there is usually some constitutional
taint, as gout, diabetes, or chronic Bright's disease. I have seen several
instances of obstinate hiccough in the later stages of chronic interstitial
nephritis.
{d) Neurotic, cases in which the primary cause is in the nervous system;
hysteria, epilepsy, shock, or cerebral tumors. Of these cases the hysterical
are, perhaps, the most obstinate.
The treatment is often very unsatisfactory. Sometimes in the milder
forms a sudden reflex irritation will check it at once. Readers of Plato's
Symposium will remember that the physician Eryximachus recommended to
Aristophanes, who had hiccough from eating too much, either to hold his
breath (which for trivial forms of hiccough is very satisfactory) or to gargle
with a little water ; but if it still continued, " tickle your nose with something
and sneeze; and if you sneeze once or twice even the most violent hiccough
is sure to go." The attack must have been of some severity, as it is stated
subsequently that the hiccough did not disappear until Aristophanes had
resorted to the sneezing.
Ice, a teaspoonful of salt and lemon-juice, or salt and vinegar, or a tea-
spoonful of raw spirits may be tried. When the hiccough is due to gastric
irritation, lavage is sometimes promptly curative. I saw a case of a week's
duration cured by a hypodermic injection of gr. ^ of apomorphia. In obsti-
nate cases the various antispasmodics have been used in succession. Pilo-
carpine has been recommended. The ether spray on the epigastrium may be
promptly curative. Hypodermics of morphia, inhalations of chloroform, the
use of nitrite of amyl and of nitroglycerin, have been beneficial in some cases.
Galvanism over the phrenic nerve, or pressure on the nerves, applied between
the heads of the sterno-cleido-mastoid muscles' may be used. Strong traction
upon the tongue may give immediate relief.
Brachial Plexus.
(1) Combined Paralysis. — The plexus may be involved in the supracla-
vicular region by compression of the nerve trunks as they leave the spine, or by
tumors and other morbid processes in the neck. Below the clavicle lesions are
more common and result from injuries following dislocation or fracture, some-
times from neuritis. A cervical rib may lead to a pressure paralysis of
the lower cord of the plexus. A not infrequent form of injury in this re-
gion follows falls or blows on the neck, which by lateral flexion of the
head and depression of the shoulder seriously stretch the plexus. The en-
tire plexus may be ruptured and the arm be totally paralyzed. The rupture
may occur anywhere between the vertebrge and the clavicle, and involve
all the cords of the plexus, or only the upper ones. The so-called " obstet-
rical palsy," due to drawing apart of the head and the shoulder during
delivery, is an instance of this sort of injury. In these cases, however, the
rupture of the plexus is usually only a partial one, involving its upper cord
alone, so that the deltoid, biceps, supra- and infra-spinati, brachialis anticus,
1036 DISEASES OF THE NERVOUS SYSTEM.
and supinator longus muscles may alone be affected. When the entire plexus
has been ruptured a complete motor and sensor}- parah'sis of the arm is pro-
duced. The roots may even be torn away from the spinal cord. The pupil will
then be contracted on the side of the injury, and the arm hang from the body
like a flail. Another common cause of lesion of the brachial plexus is luxation
of the head of the humerus, particularly the subcoracoid form.
A primary neuritis of the brachial plexus is rare. More commonly the
process is an ascending neuritis from a lesion of a peripheral branch, involving
first the radial or ulnar nerves, and spreading upward to the plexus, producing
graduall}" complete loss of power in the arm.
(2) Lesions of Individual Nerves of the Plexus.— (a) Loxg Tiioeacic
i^EEVE. — Serratus paralysis follows injury to this nerve in the neck, usu-
allv bv direct pressure yd. carrying loads, and is very common in soldiers.
It may be due to a neuritis following an acute infection or exposure. Isolated
serratus paralysis is rare. It usually occurs in connection with paralysis of
other muscles of the shoulder girdle, as in the myopathies and in progressive'
muscular atrophy. Concomitant trapezius paralysis is the most frequent. In
the isolated paralysis there is little or no deformity with the hands hanging
by the sides. There is slight abnormal obliquity of the posterior border of the
scapula and prominence of the inferior angle, but when, as so commonly hap-
pens, the middle part of the trapezius is also paralyzed, the deformity is
marked. The shoulder is at a lower level, the inferior angle of the scapula
is displaced inward and upward, and the superior angle projects upward.
When the arms are held out in front at right angles to the body the scapula
becomes winged and stands out prominently. The arm can not, as a rule,
be raised above the horizontal. The outlook of the cases due to injury or to
neuritis is good.
(&) Circumflex Nekve. — This supplies the deltoid and the teres minor.
The nerve is apt to be involved in injuries, in dislocations, bruising by a
crutch, or sometimes by extension of inflammation from the joint. Occasion-
ally the paralysis arises from a pressure neuritis during an illness. As a con-
sequence of loss of power in the deltoid, the arm can not be raised. The wast-
ing is usually marked and changes the shape of the shoulder. Sensation may
also be impaired in the skin over the muscle. The joint may be relaxed and
there may be a distinct space between the head of the humerus and the
acromion.
(c) MuscuLO-spiRAL Paealtsis ; Eadial Paralysis. — This is 'one of the
most common of peripheral palsies, and results from the exposed position of
the musculo-spiral nerve. It is often bruised in the use of the crutch, by
injuries of the arm, blows, or fractures. It is frequently injured when a
person falls asleep with the arm over the back of a chair, or by pressure of
the body upon the arm when a person is sleeping on a bench or on the ground.
It may be paralyzed by sudden violent contraction of the triceps. It is some-
times involved in a neuritis from cold, but this is uncommon in comparison
with other causes. The paralysis of lead poisoning is the result of involve-
ment of certain branches of this nerve.
A lesion when high up involves the triceps, the brachialis anticus, and the
supinator longus, as "VA'ell as the extensors of the wrist and fingers. Naturally,
in lesions just above the elbow the arm muscles and the sui^inator longus are
DISEASES OF THE PERIPHERAL NERVES. 1037
spared. The most characteristic feature of the paralysis is the wrist-drop and
the inability to extend the first phalanges of the fingers and thumb. In the
pressure palsies the supinators are usually involved and the movements of
supination can not be accomplished. The sensations may be impaired, or there
may be marked tingling, but the loss of sensation is rarely so pronounced as
that of motion.
The affection is readily recognized, but it is sometimes difficult to say upon
what it depends. The sleep and pressure palsies are, as a rule, unilateral and
involve the supinator longus. The paralysis from lead is bilateral and the
supinators are unaffected. Bilateral wrist-drop is a very common symptom
in many forms of multiple neuritis, particularly the alcoholic; but the mode
of onset and the involvement of the legs and arms are features which make the
diagnosis easy. The duration and course of the musculo-spiral paralyses are
very variable. The pressure palsies may disappear in a few days. Kecovery
is the rule, even when the affection lasts for many weeks. The electrical exam-
ination is of importance in the prognosis, and the rules laid down under
paralysis of the facial nerve hold good here.
The treatment is that of neuritis.
(d) Ulnar Nerve. — The motor branches supply the ulnar half of the deep
flexor of the fingers, the muscles of the little finger, the interossei, the adduc-
tor and the inner head of the short fiexor of the thumb, and the ulnar flexor
of the wrist. The sensory branches supply the ulnar side of the hand — two
and a half fingers on the back, and one and a half fingers on the front. Paral-
ysis may result from pressure, usually at the elbow-joint, although the nerve
is here protected. Possibly the neuritis in the ulnar nerve in some cases of
acute illness may be due to this cause. G-owers mentions the case of a lady
who twice had ulnar neuritis after confinement. Owing to paralysis of the
ulnar flexor of the wrist, the hand moves toward the radial side; adduction
of the thumb is impossible; the first phalanges can not be fiexed, and the
others can not be extended. In long-standing cases the first phalanges are
overextended and the others strongly flexed, producing the claw-hand ; but this
is not so marked as in the progressive muscular atrophy. The loss of sensa-
tion corresponds to the sensory distribution just mentioned.
(e) Median ISTerve. — This supplies the flexors of the fingers except the
ulnar half of the deep flexors, the abductor and the flexors of the thumb, the
two radial lumbricales, the pronators, and the radial flexor of the wrist. The
sensory fibres supply the radial side of the palm and the front of the thumb,
the first two fingers and half the third finger, and the dorsal surfaces of the
same three fingers.
This nerve is seldom involved alone. Paralysis results from injury and
occasionally from neuritis. The signs are inability to pronate the forearm
beyond the mid-position. The wrist can be flexed only toward the ulnar side ;
the thumb can not be opposed to the tips of flngers. The second phalanges
can not be flexed on the first; the distal phalanges of the first and second
fingers can not be fiexed; but in the third and fourth fingers this action can
be performed by the ulnar half of the flexor profundus. The loss of sensation
is in the region corresponding to the sensory distribution already mentioned.
The wasting of the thumb muscles, which is usually marked in this paralysis,
gives to it a characteristic appearance.
1038 DISEASES OF THE NERVOUS SYSTEM,
LuMBAE A]sT) Sacral Plexuses.
The lumbar plexus is sometimes involved in growths of the lymph-glands,
in psoas abscess, and in disease of the bones of the vertebrae. Of its branches
the obturator nerve is occasionally injured during parturition. When para-
lyzed the power is lost over the adductors of the thigh and one leg can not
be crossed over the other. Outward rotation is also disturbed. The anterior
crural nerve is sometimes involved in wounds or in dislocation of the hip-joint,
less commonly during parturition, and sometimes hj disease of the bones and
in psoas abscess. The special symptoms of affection of this nerve are paralysis
of the extensors of the knee with wasting of the muscles, anesthesia of the
antero-lateral parts of the thigh and of the inner side of the leg to the big
toe. This nerve is sometimes involved early in growths about the spine, and
there may be pain in its area of distribution. Loss of the power of abducting
the thigh results from paralysis of the gluteal nerve, which is distributed to
the gluteus medius and minimus muscles.
External Cutaneous Nerve. — A peculiar form of sensory disturbance, con-
fined to the territory of this nerve, was first described by Bernhardt in 1895,
and a few months later by Eoth, who gave it the name of meralgia parcesthet-
ica. The disease is probably due to a neuritis which seems to originate in that
part of the nerve where it passes under Poupart's ligament, just internal to
the anterior superior iliac spine. The nerve is usually tender on pressure at
this point. The disease is more common in men. Musser and Sailer in 1900
collected 99 cases, of which To were in men. A large number of the cases are
attributable to direct traumatism or to simj)le pressure on the nerve by the
aponeurotic canal through which it passes. Pregnancy is among the more
common causes in women. The sensory disturbances consist of various forms
of parsesthesia located over the outer side of the thigh, oftentimes with some
actual diminution in the acuity of sense perception. The symptoms in varying
intensit}" may persist for years, and the discomfort in some cases be so great,
and so much exaggerated even by the mere touch of the clothing, that patients
may be greatly incapacitated thereby. Excision of the nerve as it passes ujider
Poupart's ligament has given good results.
The sacral plexus is frequently involved in tumors and inflammations
within the pelvis and may be injured during parturition. Neuritis is com-
mon, usually an extension from the sciatic nerve.
Of the branches, the sciatic nerve, when injured at or near the notch, causes
paralysis of the flexors of the legs and the muscles below the knee, but injury
below the middle of the thigh involves only the latter muscles. There is also
anaesthesia of the outer half of the leg, the sole, and the greater portion of
the dorsum of the foot. Wasting of the muscles frequently follows, and there
may be trophic disturbances. In paralysis of one sciatic the leg is fixed at
the knee by the action of the quadriceps extensor and the patient is able to
walk.
Paralysis of the small sciatic nerve is rarely seen. The gluteus maximus
is involved and there may be difficulty in rising from a seat. There is a strip
of anesthesia along the back of the middle third of the thigh.
External Popliteal Nerve. — -Paralysis involves the peronsei, the long ex-
tensor of the toes, tibialis anticus, and the extensor brevis digitorum. The
1
DISEASES OF THE PERIPHERAL NERVES. 1039
ankle can not be flexed, resulting in a condition kno^m as foot-drop, and as
the toes can not be raised the whole leg must be lifted, producing the charac-
teristic steppage gait seen in so many forms of peripheral neuritis. In long-
standing cases the foot is permanently extended and there is wasting of the
anterior tibial and peroneal muscles. The loss of sensation is in the outer
half of the front of the leg and on the dorsum of the foot.
Internal Popliteal Nerve. — When paralyzed, plantar flexion of the foot and
flexion of the toes are impossible. The foot can not be adducted, nor can the
patient rise on tiptoe. In long-standing cases talipes calcaneus follows and
the toes assume a claw-like position from secondary contracture, due to over-
extension of the proximal and flexion of the second and third phalanges.
Sciatica.
This is, as a rule, a neuritis either of the sciatic nerve or of its cords of
origin. It may in some instances be a functional neurosis or neuralgia.
It occurs most commonly in adult males. A history of rheumatism or of
gout is present in many cases. Exposure to cold, particularly after heavy
muscular exertion, or a severe wetting are not uncommon causes. Within the
pelvis the nerves may be compressed by large ovarian or uterine tumors, by
lymphadenomata, by the foetal head during labor; occasionally lesions of the
hip- joint induce a secondary sciatica. More commonly, however, the condition
is due to chronic arthritis of the spinal column. The condition of the nerve
has been examined in a few cases, and it has often been seen in the operation
of stretching. It is, as a rule, swollen, reddened, and in a condition of inter-
stitial neuritis. The affection may be most intense at the sciatic notch or in
the nerve about the middle of the thigh.
Of the symptoms, pain is the most constant and troublesome. The onset
may be severe, with slight pyrexia, but, as a rule, it is gradual, and for a time
there is only slight pain in the back of the thigh, particularly in certain posi-
tions or after exertion. Soon the pain becomes more intense, and instead of
being limited to the upper portion of the nerve, extends down the thigh, reach-
ing the foot and radiating over the entire distribution of the nerve. The
patient can often point out the most sensitive spots, usually at the notch or
in the middle of the thigh ; and on pressure these are exquisitely painful. The
pain is described as gnawing or burning, and is usually constant, but in some
instances is paroxysmal, and often worse at night. On walking it may be very
great ; the knee is bent and the patient treads on the toes, so as to relieve the
tension on the nerve. In protracted cases there may be much wasting of
the muscles, but the reaction of degeneration can seldom be obtained. In these
chronic cases cramp may occur and fibrillar contractions. Herpes may develop,
but this is unusual. In rare instances the neuritis ascends and involves the
spinal cord.
The duration and course are extremely variable. As a rule it is an ob-
stinate affection, lasting for months, or even, with slight remissions, for years.
Kelapses are not uncommon, and the disease may be relieved in one nerve only
to appear in the other. In the severer forms the patient is bedridden, and
such cases prove among the most distressing and trying which the physician
is called upon to treat.
1040 DISEASES OF THE NERVOUS SYSTEM.
In the diagnosis it is important, in the first place, to determine whether
the disease is primary, or secondary to some affection of the pelvis or of the
spinal cord. A careful rectal examination should be made, and, in women,
pelvic tumor should he excluded. Lumbago may be confounded with it. Af-
fections of the hip-joint are easih' distinguished by the absence of tenderness
in the course of the nerve and the sense of pain on movement of the hip-joint
or on pressure in the region of the trochanter. There are instances of sacro-
iliac disease in which the patient complains of pain in the upper part of the
thigh, which may sometimes radiate; but careful examination will readily
distinguish between the affections. Pressure on the nerve trunks of the cauda
equina, as a rule, causes bilateral pain and disturbances of sensation, and, as
double sciatica is rare, these circumstances always suggest lesion of the nerve
roots. Between the severe lightning pains of tabes and sciatica the differences
are usually well defined.
Treatment. — The spinal column should be carefully and systematically ex-
amined, for numerous cases have been relieved by orthopaedic procedures. The
pelvic organs should also be investigated. Constitutional conditions, such as
rheumatism and gout, should receive appropriate treatment. In a few cases
with pronounced rheumatic histor}^ which come on acutely with fever, the
salicylates seem to do good. In other instances they are quite useless. If
there is a suspicion of syphilis, the iodide of potassium should be employed,
and in gouty cases salines.
Eest in bed ^vith fixation of the limb by means of a long splint is a most
valuable method of treatment in many cases, one upon which Weir Mitchell
has specially insisted. I have known it to relieve, and in some instances to
cure, obstinate and protracted cases which had resisted all other treatment.
Hydrotherapy is sometimes satisfactory, particularly the warm baths or the
mud baths. Many cases are relieved by a prolonged residence at one of the
thermal springs.
Antip}Tin, antifebrin, and quinine are of doubtful benefit.
Local applications are more beneficial. The hot iron or the thermo-cautery
or blisters relieve the pain temporarily. Deep injections into the nerves give
great relief and may be necessary for the pain. It is best to use cocaine at
first, in doses of from an eighth to a quarter of a grain. If the pain is un-
bearable morphia may be used, but it is a dangerous remed}^ in sciatica and
should be withheld as long as possible. The disease is so protracted, so liable
to relapse, and the patient's morale so undermined by the constant worry and
the sleepless nights, that the danger of contracting the morphia habit is very
great. On no consideration should the patient be permitted to use the h}qDO-
dermic needle himself. It is remarkable how promptly, in some cases, the
injection of distilled water into the nerve will relieve the pain. Acupuncture
may also be tried; the needles should be thrust deeply into the most painful
spot for a distance of about 2 inches, and left for from fifteen to twenty
minutes. The injection of chloroform into the nerve has also been recom-
mended.
Electricity is an uncertain remedy. Sometimes it gives prompt relief; in
other cases it may be used for weeks without the slightest benefit. It is most
serviceable in the chronic cases in which there is wasting of the legs, and*
ehould be combined with massage. The galvanic current should be used; a
GENERAL AND FUNCTIONAL DISEASES. 1041
tlat electrode should be placed over the sciatic notch, and a smaller one used
along the course of the nerve and its branches. In very obstinate cases nerve-
stretching may be employed. It is sometimes successful • but in other in-
stances the condition recurs and is as bad as ever.
G. GENERAL AND FUNCTIONAL DISEASES.
I. ACUTE DELIRIUM (BeU's Mania).
Definition. — Acute delirium which runs a rapidly fatal course, with slight
fever, and in which post mortem no lesions are found sufficient to account for
the disease.
Etiological factors are emotional strain, mental shock and distress, physical
pain, toxaemia or infection. It may occur during convalescence from fevers.
It is a rare disease, and almost all authors are agreed that, with few exceptions,
it is peculiar to women. Cases are reported by many old writers under the
term brain fever or phrenitis. Bell, at the time Superintendent of the McLean
Asylum, described it * accurately under the designation, " a form of disease
resembling some advanced stages of mania and fever."
The disease may set in abruptly or be preceded by a period of irritability,
restlessness, and insomnia. The mental symptoms develop with rapidity and
may quickly reach a grade of the most intense frenzy. There are the wildest
hallucinations and outbreaks of great violence. The patient talks incessantly,
but incoherently and unintelligibly. JSTo sleep is obtained, and at last, worn
out with the intensity of the muscular movements, the patient becomes utterly
prostrated and assumes the sitting or recumbent posture. There may some-
times be definite salaam movements, and in a case which I saw at Westphal's
clinic the patient incessantly made motions as if working a pump handle. After
a period of intense bodily excitement, lasting for from twenty-four to thirty-
six hours or longer, the patient can be examined, and presents the conditions
which Bell described as typho-mania. The temperature ranges from 102° to
104°, or even higher. The tongue is dry, the pulse rapid and feeble; some-
times there are seen on the skin bullae and pustules, and frequently sores from
abrasion and self-inflicted injuries. Toward the close or, according to Spitzka,
even during the development of the disease there may be lucid intervals. There
may be petechia on the skin, and often there is marked congestion of the face
and extremities. The duration of the disease is variable. Very acute cases
may terminate within a week ; others persist for two or even three weeks. The
course of the disease is almost uniformly fatal. The anatomical condition is
practically negative, or at any rate presents nothing distinctive. There is great
venous engorgement of the vessels of the meninges and of the gray cortex.
In two cases in which I made a careful microscopical examination of the gray
matter there were perivascular exudation and leucocytes in the lymph sheaths
and perigangliar spaces. In the inspection of fatal cases of acute delirium
careful examination should be made of the lungs and ileum. It should be
borne in mind that in a majority of the cases dying in this manner, there is
engorgement of the bases of the lungs or even deglutition pneumonia.
♦ American Journal of Insanity, 1849.
1042 DISEASES OF THE XERVOUS SYSTEM.
The nature of the disease is quire unknown. Some of the cases suggest
acute iufe.Tion, Spitzka thinks that it is due to an autochthonous nerve
poison.
Diagnosis, — There are several liiseases which may present identical symp-
t ::_-. A? Bt'-l :'-:::::'_:- :u hi- rarier. the first glance in many cases suggests
r.Tl-rii i-r'cr. > lu: ; ;. :i v.ii^n T::e patient is seen after the violence of the
mania has suV-ilei. He gives two instances of this which were admitted
from a general hospital. Enlargement of the spleen, the occurrence of spots,
and the history give clews for the separation of the cases; but there are in-
stances in. which it is at first impossible to decide. Moreover, typhoid fever
may set in with the most intense delirium. The existence of fever is the most
deceptive symptom, and its combination with delirium and dry tongue so com-
monly means typhoid fever that it is very difficult to avoid error.
Acute pneumonia may come on with violent maniacal delirium and the
pulmonary symptoms may be entirely masked.
Occasionally acute uraemia sets in suddenly with intense mania, and finally
subsides into a fatal coma. The condition of the ttrine and the absence of
fever would be important diagnostic features.
The character of the delirium is quite different from that of mania a potu.
It may be extremely difficult to differentiate acute delirium from certain cases
of cortical meningitis occurring in connection with pneumonia, ulcerative
endocarditis or tuberculosis, or due to extension from disease of the ear. This
sets ia more frequently vrith a chill, and there may be convulsions.
Treatment. — Even though bodily prostration is apt to come on early and
be profomid, in the case of a robust man free venesection might be tried. I
I have been criticised for this advice, but repeat it. It is not at all improb-
able that some of the many cases of mania in which Benjamin Eush let blood
with such benefit belonged to this class of affections. Considering its remark-
a^'le cahnlns' influence in febrile delirium, the cold bath or the cold pack should
be e::.::i:" "i. Morphia and chloroform may be administered and hyoscine
and the bromides may be tried. iKjafft-Ebing states that Solivetti has obtained
good results by the use of ergotin. ITnf ortunately, as as} lum reports show, the
disease is almost uniformly fatal.
II. PARALYSIS AGITAI^S.
(Parkinson's Disease : Shaking Palsy.)
Defi.nition, — A chronic affection of the nervous system, characterized by
muscular vreakness. tremors, and rigidity.
Etiolo^. — Men are more frequently affected than women. It rarely
- ::ur= under forty, but instances have been reported in which the disease began
a : r: zhe twentieth year. It is by no means an uncommon affection. Direct
__^rT;i::v is rare, but the patients often belong to families in which there are
c:ii:: nervous affections. Among exciting causes may be mentioned exposure
to c i : ai-l wet, and business worries and anxieties. In some instances the
c:~ >- : - i i" wed directly upon severe mental shock or trauma. Cases have
: r i- :: - 1 after the specific fevers. Malaria is believed by some to be an
: ::ant factor, but of this there is no satisfactory evidence.
GENERAL AND FUNCTIONAL DISEASES. 1043
Morbid Anatomy. — Xo constant lesions have been found. The similarity
between certain of the features of Parkinson's disease and those of old age
suggest that the affection may depend upon a premature senility of certain
regions of the brain. Our organs do not age uniformly, but in some, owing to
hereditary disposition, the process may be more rapid than in others. " Park-
inson's disease has no characteristic lesions, but on the other hand it is not a
neurosis. It has for an anatomical basis the lesions of cerebro-spinal senility,
which only differ from those of true senility in their early onset and greater
intensity" (Dubief). The important changes are doubtless in the cerebral
cortex.
Symptoms. — The disease begins gradualb^ usually in one or other hand,
and the tremor may be either constant or intermittent. With this may be asso-
ciated weakness or stiffness. At first these symptoms may be present only
after exertion. Although the onset is slow and gradual in nearly all cases,
there are instances in which it sets in abruptly after fright or trauma. Wlien
well established the disease is very characteristic, and the diagnosis can be made
at a glance. The four prominent symptoms are tremor, weakness, rigidity,
and the attitude.
Tee:\ior. — This may be in the four extremities or confined to hands or
feet ; the head is not so commonly affected. The tremor is usually marked in
the hands, and the thumb and forefinger display the motion made in the act
of rolling a pill. At the wrist there are movements of pronation and supina-
tion, and, though less marked, of fiexion and extension. The upper-arm mus-
cles are rarely involved. In the legs the movement is most evident at the
ankle-joint, and less in the toes than in the fingers. Shaking of the head is
less frequent, but does occur, and is usually vertical, not rotatory. The rate
of oscillation is about five per second. Any emotion exaggerates the movement.
The attempt at a voluntary movement may check the tremor (the patient may
be able to thread a needle), but it returns with increased intensity. The
trem.ors cease, as a rule, during sleep, but persist when the muscles are not
in use. The writing of the patient is tremulous and zigzag.
Weakness. — Loss of power is present in all cases, and may occur even be-
fore the tremor, but is not very striking, as tested by the dynamometer, until
the late stages. The weakness is greatest where the tremor is most developed.
The movements, too, are remarkably slow. There is rarely complete loss of
power.
KiGiDiTT may early be expressed in a slowness and stiffness in the volun-
tary movements, "which are performed with some effort and difficulty, and all
the actions of the patient are deliberate. This rigidit}^ is in all the muscles,
and leads ultimately to the characteristic attitude.
Attitude axd Gait. — The head is bent forward, the back is bowed, and
the arms are held away from the body and are somewhat flexed at the elbow-
joints. The face is expressionless, and the movements of the lips are
slow. The eyebrows are elevated, and the whole expression is immobile or
mask-like, the so-called Parkinson's mask. The voice, as pointed out by Buz-
zard, is apt to be shrill and piping, and there is often a hesitancy in beginning
a sentence; then the words are uttered with rapidity, as if the patient was in
a hurry. This is sometimes in striking contrast to the scanning speech of
insular sclerosis. The fingers are flexed and in the position assumed when the
1044 DISEASES OF THE NERVOUS SYSTEM.
hand is at rest; in the hite stages the_y eau uot be cA'tended. Occasionally
there is overextension of the terminal phalanges. The hand is usually turned
to"0'ard the ulnar side and the attitude somewhat resembles that of advanced
cases of rheumatoid arthritis. In the late stages there are contractures at the
elbows, knees, and ankles. The movements of the patient are characterized
by great deliberation. He rises from the chair slowly in the stooping atti-
tude, with the head projecting forward. In attempting to walk the steps
are short and hurried, and, as Trousseau remarks, he appears to be running
after liis centre of gravity. This is termed festination or propulsion, in con-
tradistinction to a peculiar gait observed when the patient is pulled backward,
when he makes a number of steps and would fall over if not prevented — retro-
pulsion.
The REFLEXES are normal in most cases, but in a few they are exaggerated.
Of SENSORY disturbances Charcot has noted abnormal alterations in the
temperature sense. The patient may complain of subjective sensations of heat,
either general or local — a phenomenon which may be present on one side only
and associated with an actual increase of the surface temperature, as much
as 6° F. (Gowers). In other instances, patients complain of cold. Localized
sweating may be present. The skin, especially of the forehead, may be thick-
ened. The mental condition rarely shows any change.
Variations in the Symptoms. — The tremor may be absent, but the rigid-
ity, weakness, and attitude are sufficient to make the diagnosis. The disease
may be hemiplegic in character, involving only one side or even one limb.
Usually these are but stages of the disease.
Diagnosis. — In well-developed cases the disease is recognized at a glance.
The attitude, gait, stiffness, and mask-like expression are points of as much
importance as the oscillations, and usualh'^ serve to separate the cases from
senile and other forms of tremor. Disseminated sclerosis develops earlier, and
is characterized by the nystagmus, and the scanning speech, and does not pre-
sent the attitude so constant in paralysis agitans. Yet Schultze and Sachs
have reported cases in which the signs of multiple sclerosis have been asso-
ciated with those of paralysis. The hemiplegic form might be confounded
with post-hemiplegic tremor, but the history, the mode of onset, and the greatly
increased reflexes would be sufficient to distinguish the two. The Parkinsonian
face is of great importance in the diagnosis of the obscure and anomalous
forms.
The disease is incurable. Periods of improvement may occur, but the tend-
ency is for the affection to proceed progressively downward. It is a slow,
degenerative process and the cases last for years.
Treatment. — There is no method which can be recommended as satisfac-
tory in any res]3ect. Arsenic, opium, and hyoscyamine may be tried, but the
friends of the patient should be told frankly that the disease is incurable,
and that nothing can be done except to attend to the physical comforts of the
patient. Eegulated and systematized exercises should be carried out
Other Forms of Tremor.
(a) Simple Tremor. — This is occasionally found in persons in whom it is
impossible to assign any cause. It may be transient or persist for an indefi-
GENERAL AND FUNCTIONAL DISEASES. 1045
nite time. It is often extremely slight, and is aggravated by all causes which
lower the vitality.
(5) Hereditary Tremor. — C. L. Dana has reported remarkable cases of
hereditary tremor. It occurred in all the members of one family, and begin-
ning in infancy continued without producing any serious changes.
(c) Senile Tremor. — With advancing age tremulousness during muscular
movements is extremely common, but is rarely seen under seventy. It is
always a fine tremor, which begins in the hands and often extends to the
muscles of the neck, causing slight movement of the head.
(d) Toxic tremor is seen chiefly as an efl^ect of tobacco, alcohol, lead, or
mercury; more rarely in arsenical or opium poisoning. In elderly men who
smoke much it may be entirely due to the tobacco. One of the commonest
forms of this is the alcoholic tremor, which occurs only on movement and has
considerable range. Lead tremor is considered under lead poisoning, of which
it constitutes a very important symptom.
(e) Hysterical tremor, which usually occurs under circumstances which
make the diagnosis easy, will be considered in the section on hysteria.
III. ACUTE CHOREA.
(Sydenham's Chorea; St. Vitus's Dance.)
Definition. — A disease chiefly afi'ecting children, characterized by irregular,
involuntary contraction of the muscles, a variable amount of psychical dis-
turbance, and a remarkable liability to acute endocarditis.
Etiology. — Sex. — Of 554 cases which I analyzed from the Philadelphia
Infirmary for Diseases of the Nervous System, 71 per cent were in females
and 29 per cent in males. Of 808 Johns Hopkins Hospital cases, 71.2 per
cent were females (Thayer and Thomas).
Age. — The disease is most common between the ages of five and fifteen.
Of 522 cases, 380 occurred in this period; 84.5 per cent in Thayer and
Thomas' series. It is rare among the negroes and native races of America.
Only 25 of the Johns Hopkins Hospital cases were in negroes. The cases are
most numerous when the mean relative humidity is excessive and the baro-
metric pressure low (Lewis).
Eheumatism. — A causal relationship between rheumatism and chorea has
been claimed by many since the time of Bright. The English and French
writers maintain the closeness of this connection ; on the other hand, German
authors, as a rule, regard the connection as by no means very close. Of the
554 cases, in 15.5 per cent there was a history of rheumatism in the family.
In 88 cases, 15.8 per cent, there was a history of articular swelling, acute or
subacute. In 33 cases there were jiains, sometimes described as rheumatic, in
various parts, but not associated with joint trouble. Adding these to those
with manifest articular trouble, the percentage is raised to nearly 21. It is
rather remarkable that in our Baltimore series the percentage with a history
of rheumatism was the same — 21.6.
We find two groups of cases in which acute arthritis is present in chorea.
In one, the arthritis antedates by some months or years the onset of the chorea,
and does not recur before or during the attack. In the other group, the chorea
sets in with or follows immediately upon the acute arthritis. In some instances
1046 DISEASES OF THE NERVOUS SYSTEM.
it is impossible to decide wlietheT the joint symptoms or the movements have
appeared first. It is difficult to differentiate the cases of irregular paiiis with-
out definite joint affection. It is probable that many of them are rheumatic,
and yet I think it vrould be a mistake to regard as such all cases in children
in which there are complaints of vague paius in the bones or muscles — so-called
growing pains. It should never be forgotten, however, that a slight articular
swelling may be the sole manifestation of rheumatism in a child — so slight,
indeed, that the disease may be entirely overlooked.
Heaet-disease. — Endocarditis is believed by some writers to be the cause
of the disease. The particles of fibrin and vegetations froui the valves pass as
emboli to the cerebral vessels. On this view, which we shall discuss later,
chorea is the result of an embolic process occurring in the course of a rheu-
matic endocarditis.
IifFECTious Diseases. — Scarlet fever with artlixitie manifestations may
be a direct antecedent. Sturges states that a history of previous whooping-
cough occurs more frequently in choreic than in other children, but I find
no evidence of this in the Infirmary records. With the exception of rheumatic
fever, there is no intimate relationship between chorea and the acute diseases
incident to childhood. It may be noted in contrast to this that the so-called
canine chorea is a common sequel of distemjjer. Chorea has been known to
develop in the course of an acute pyaemia, and to follow gonorrhoea and puer-
peral fever.
Asr^iriA is less often an antecedent than a sequence of chorea, and though
cases develop in children who are anaemic and in poor health, this is by no
means the rule. Chorea may develop in chlorotic girls at puberty.
Pbegnaxct. — A choreic patient may become pregnant; more frequently
the disease occurs during pregnancy; sometimes it develops post partum.
Buist, of Dundee (Trans. Edin. Obs. Soc, 1895), has tabulated carefully the
recorded cases to that date. Of 226 cases, in 6 the chorea preceded the preg-
nancy; in 105 it occcurred during the pregnane}^; in 31 in recurrent preg-
nancies; 45 cases terminated fatally, and in 16 cases the chorea developed post
partum. The alleged frequency in illegitimate primiparse is not borne out by
his figures. Begimiing in the first three months were 108 cases, in the second
three months TO cases, in the last three months 25 cases. The disease is often
severe, and maniacal symptoms may develop.
A tendency to the disease is found in certain families. In 80 cases there
was a history of attacks of chorea in other members. In one instance both
mother and grandmother had been affected. High-strung, excitable, nervous
children are especially liable to the disease. Fright is considered a frequent
cause, but in a large majority of the cases no close connection exists between
the fright and the onset of the disease. Occasionally the attack sets in at
once. Mental worry, trouble, a sudden grief, or a scolding may apj)arently
be the exciting cause. The strain of education, particularly in girls during
the third hemidecade, is a most important factor in the etiology of the disease.
Bright, intelligent, active-minded girls from ten to fourteen, ambitious to do
well at school, often stimulated in their efforts by teachers and parents, form
a large contingent of the cases of chorea in hospital and private practice.
Sturges has called special attention to this sclwol-made chorea as one serious
evil in our modern method of forced education. Imitation, which is men-
GENERAL AND FUNCTIONAL DISEASES. 1047
tioned as an exciting ca^^se, is extremely rare, and does not appear to have
influenced the onset in a single case in the Infirmary records.
The disease may rapidly follow an injury or a slight surgical operation.
Eeflex irritation was believed to play an important role in the disease, particu-
larly the presence of worms or genital irritation; but I have met with no in-
stance in which the disease could be attributed to either of these causes. Local
spasm, particularly of the face — the habit chorea of Mitchell — may be asso-
ciated with irritation in the nostrils and adenoid growths in the vault of the
pharynx, as pointed out by Jacobi.
It has been claimed by Stevens that ocular defects lie at the basis of many
cases of chorea, and that with the correction of these the irregular movements
disappear. The investigations of De Schweinitz show that ocular defects do
not occur in greater proportion in choreic than in other children. A majority
of the cases in which operation has been followed by relief have been instances
of tic, local or general.
Morbid Anatomy and Pathology. — jSJ"o constant lesions have been found
in the nervous system in acute chorea. Vascular changes, such as hyaline
transformation, exudation of leucocytes, minute hsemorrhages, and thrombosis
of the smaller arteries, have been described.
Embolism of the smaller cerebral vessels has been found, and there are
on record 7 cases of embolism of the central artery of the retina (H. M.
Thomas, 1901). Based on the presence of emboli, Kirkes and others have
supported what is known as the embolic theory of the disease. Endocarditis
is by far the most frequent lesion in Sydenham's chorea. With no disease,
not excepting rheumatism, is it so constantly associated. I have collected
from the literature (to July, 1894) the records of 73 autopsies; there were 63
with endocarditis.* The endocarditis is usually of the simple variety, but
the ulcerative form has occasionally been described.
We are still far from a solution of all the problems connected with chorea.
Unfortunately, the word has been used to cover a series of totally diverse dis-
orders of movement, so that there are still excellent observers who hold that
chorea is only a symptom, and is not to be regarded as an etiological unit. The
chorea of childhood, the disease which Sydenham described, presents, however,
characteristics so unmistakable that it must be regarded as a definite, substan-
tive afEection. We can not discuss fully, but only indicate briefl}^^, certain of
the theories which have been advanced with regard to it. The most generally
accepted view is that it is a functional hrain disorder affecting the nerve-
centres controlling the motor apparatus, an instability of the nerve-cells,
brought about, one supposes by hj^Dersemia, another by anasmia, a third hj
psychical influences, a fourth hj irritation, central or peripheral. Of the actual
nature of this derangement we know nothing, nor, indeed, whether the changes
are primary and the result of a faulty action of the cortical cells or whether the
impulses are secondarily disturbed in their course down the motor path. The
predominance of the disease in females, and its onset at a time when the edu-
cation of the brain is rapidly developing, are etiological facts which Sturges
has urged in favor of the view that chorea is an expression of functional insta-
bility of the nerve-centres.
* Osier, Chorea and Choreiform Affections, 1894.
1048 DISEASES OF THE NERVOUS SYSTEM.
The emki&iic Hnmry originiaMj advaneed bj Kirkes hz& a solid basis
of fact, ibiat it is not compiielfteiisive enomgli, as all of the cases can not be
broHgiit witMn its limits. There are instances without endocarditis and
without, iso far as can h& ascertained, plugging of cerebral vessels; and
tJieipe are also easies with extensive endocarditis in "vrhicli tlie histological
examimatiQn. of the braiit, so far as embolism is concerned, was negative.
In favor of the embolic view is the experimental production in animals of
chorea hj Bosenthal, and later by Money, by injecting fine particles into
the caiotidsw
Lately, as indeed might be expected, chorea has been regarded as an infec-
imsis iisease. STothing definite has yet been determined. In favor of this
view- it has beea "niwed, as it is impossihle to refer the chorea to endocarditis or
the endoeaiditis in aE cases to rheumatism, that both have their origin in a
common eawse, some infeetions agent, which is capable also, in persons predis-
posed, of exciting articiQlar disease. Cases have been reported in scarlet fever
wiiii arthritic manifestations, in puerperal fever, and rhenmatism, also after
gQDorrhflea, and such facts are suggestive at least of the association of the
disease with, infective processes. Possibly, as has been suggested by some
writeic^ the pairalytie conditions associated with chorea may be analogous to
tiiose which occur in typhoid and certain of the infections diseases. On the
other hand, there are conditions extremely difficult to harmonize with this
view. The prominent psychical element is certainly one of the most serious
efcjections, since there can be no doubt that ordinary chorea may rapidly follow
a fright or a siadden emotion.
S^mptomsL — Three groups of cases may be recognized — ^the mild, severe,
and maniacal dboiea.
MM Chjorea. — In this the afection of the mnsd^ is slight, the speech
is not^s^sju^ disturbed, and the general health not impaired. Premoni-
tory symptoms are shown in restlessness and inability to sit still, a condition
Widl diaiacterized by the term " fidgets." There are emotional disturbances,
smch as crying s" ■:-"> :r sometimes night-terrors. There may be pains in the
limbs and headiil-r. Digestive disturbances and an ami a may be present. A
<3iiange in the temperament is frequently noticed, and a docile, qniet child
may become cro^ and irritable. After these symptoms have persisted for a
wei^ or moie the characteristic involuntary movements begin, and are often
fiist noticed at the table, when the child spills a tumbler of water or upsets a
platcL There may be only awkwardness or slight incoordination of voluntary
movem.eD.ts, or constant irregular clonic spasms. The Jerky, irregular char-
acter of the m.oviran<aits differentiates them from almost every other disorder
of motion. In the mild cases only one hand, or the hand and face, are aif eeted,
aad it may not spread to the other side.
In the second giade, the mwere form, the movements become general and
the psiisit may be umable to get about or to feed or undress herself, owing
to the constant, irregular, clonic contractions of the various muscle groups.
The speech is also affected, and for days the child may not be able to talk.
Often with iBie onset of the severer symptoms there is loss of power on one
side or in the limb most aSected.
Tlie Oiiid and mosi; extreme form, the so-called maniacal chorea, or
ehm-ea himMdens, is tmly a terrible disease, and may develop out of the ordi-
GENERAL AND FUNCTIONAL DISEASES. 1049
nary form. These cases are more common in adult women and may develop
during pregnancy.
Chorea begins, as a rule, in the hands and arms, then involves the face, and
subsequently the legs. The movements may be confined to one side — ^hemi-
chorea. The attack begins of tenest on the right side, though occasionally it is
general from the outset. One arm and the opposite leg may be involved. In
nearly one-fourth of the cases speech is affected; this may amount only to an
embarrassment or hesitancy, but in other instances it becomes an incoherent
jumble. In very severe cases the child will make no attempt to speak. The
inability is in articulation rather than in phonation. Paroxysms of panting
and of hard expiration may occur, or odd sounds may be produced. As a rule
the movements cease during sleep.
A prominent symptom is muscular weakness, usually no more than a con-
dition of paresis. The loss of power is slight, but the weakness may be shown
by an enfeebled grip or by a dragging of the leg or limping. In his original
account Sydenham refers to the "unsteady movements of one of the legs,
which the patient drags." There may be extreme paresis with but few move-
ments— the paralytic chorea of Todd. Occasionally a local paralysis or weak-
ness remains after the attack.
It is doubtful whether choreic spasms extend to the muscles of organic
life. The japid action and disturbed rhythm of the heart present nothing
peculiar to the disease, and there is no support for the view that irregular con-
tractions occur in the papillary muscles.
Heart Symptoms'. — Neurotic. — As so many of the subjects of chorea are
nervous girls, it is not surprising that a common symptom is a rapidly acting
heart. Irregularity is not so special a feature in chorea as rapidity. The
patients seldom complain of pain about the heart.
Hcemic Murmurs. — With angemia and debility, not uncommon associates
of chorea in the third or fourth week, we find a corresponding cardiac condi-
tion. The impulse is diffuse, perhaps wavy in thin children. The carotids
throb visibly, and in the recumbent posture there may be pulsation in the cer-
vical veins. On auscultation a systolic murmur is heard at the base, perhaps,
too, at the apex, soft and blowing in quality.
Endocarditis. — As in rheumatism, so in chorea, acute valvulitis rarely
gives evidence of its presence by symptoms. It must be sought, and clinical
experience has shown that it is usually associated with murmurs at one or
other of the cardiac orifices.
For the guidance of the practitioner the following statements may be
made:
(1) In thin, nervous children a systolic murmur of soft quality is ex-
tremely common at the base, with accentuation of the second sound, particu-
larly at the second left costal cartilage, and is probably of no moment.
(2) A systolic murmur of maximum intensity at the apex, and heard
also along the left sternal margin, is not uncommon in anaemic, enfeebled
states, and does not necessarily indicate either endocarditis or insufficiency.
(3) A murmur of maximum intensity at apex, with rough quality, and
transmitted to axilla or angle of scapula, indicates an organic lesion of the
mitral valve, and is usually associated with signs of enlargement of the heart.
(4) When in doubt it is much safer to trust to the evidence of eye and
1050 DISEASES OF THE NERVOUS SYSTEM.
hand than to that of the ear. If the apex heat is in the normal position,
and the area of dulness not increased yertically or to the right of the stemmn,
there is probably no serious vahTilar disease.
(5) The endocarditis of chorea is almost invariably of the simple or
Trarty form, and in itself is not dangerous; but it is apt to lead to those
sclerotic changes in the valve which produce incompetenc}'. Of 140 patients
examined more than tvro years after the attack, I found the heart normal in.
51 ; in 17 there was functional disturbance, and 73 presented signs of organic
heart-disease.
(6) Pericarditis is an occasional complication of chorea, usually in cases
with well-marked rheumatism.
In an analysis of the cases at the Johns Hopkins Hospital, Thayer found
evidence of involvement of the heart in 25 per cent of the out-patients and
in more than 50 per cent of the cases in the wards. Cardiac involvement was
more common in the cases with a history of rheumatism, and was much more
frequent in the relapses.
Sexsort Distuebances. — Pain in the affected limbs is not common.
Occasionally there is soreness on pressure. There are cases, usually of hemi-
chorea, in which pain in the limbs is a marked s^Tuptom. AYeir Mitchell has
spoken of these as painful choreas. Tender points along the lines of emergence
of the spinal nerves or along the course of the nerves of the limbs are rare.
Psychical distuebaxces are common, though in a majority of the cases
slight in degree. Irritability of temper, marked wilfulness, and emotional
outbreaks may indicate a complete change in the character of the child. There
is deficiency in the powers of concentration, the memory is enfeebled, and the
aptitude for study is lost. Earely there is progressive impairment of the
intellect with termination in actual dementia. Acute melancholia has been
described (Edes). Hallucinations of sight and hearing may occur. Patients
may behave in an odd and strange manner and do all sorts of meaningless acts.
By far the most serious manifestation of this character is the maniacal de-
lirium, occasionally associated with the very severe cases — chorea insaniens.
Usually the motor disturbance in these cases is aggravated, but it has been
overlooked and patients have been sent to an asylum.
The psychical element in chorea is apt to be neglected by the practitioner.
It is always a good plan to tell the parents that it is not the muscles alone
of the child which are affected, but that the general irritability and change
of disposition, so often found, really form part of the disease.
The condition of the reflexes in chorea is usually normal. Trophic
lesions rarely occur in chorea unless, as some writers have done, we regard
the joint troubles as arthropathies occurring in the course of a cerebro-spinal
disease.
Pever, usually slight, was present in all but one of 110 cases treated in
my wards (Thayer). H. A. Hare states that in monochorea the tempera-
ture on the affected side may be elevated; but this is not an invariable rule.
Endocarditis ma}^ occur with little if any rise in temperature; but, on the
other hand, with an acute arthritis, severe endocarditis or pericarditis, and in
the cases of maniacal chorea, the fever may range from 102° to 104°.
CuTAXEOUs Affectioxs. — The pigmentation, which is not uncommon, is
due to the arsenic. Herpes zoster occasionally occurs. Certain skin eruptions,
GENERAL AND FUNCTIONAL DISEASES. 1051
usually regarded as rheumatic in character, are not uncommon. Erythema
nodosum has been described and I have seen several cases with a purpuric
urticaria. There may, indeed, be the more aggravated condition of rheumatic
purpura, known as Schonlein's peliosis rheumatica. Subcutaneous fibrous
nodules, which have been noted by English observers in many cases of chorea,
associated with rheumatism, are extremely rare in the United States.
Duration and Termination. — From eight to ten weeks is the average dura-
tion of an attack of moderate severity. Chronic chorea rarely follows the
minor disease which we have been considering. The cases described under
this designation in children are usually instances of cerebral sclerosis or Fried-
reich's ataxia; but occasionally an attack which has come on in the ordinary
way persists for months or years, and recovery ultimately takes place. A
slight grade of chorea, particularly noticeable under excitement, may persist
for months in nervous children.
The tendency of chorea to recur has been noticed by all writers since
Sydenham first made the observation. Of 410 cases analyzed for this purpose,
240 had one attack, 110 had two attacks, 35 three attacks, 10 four attacks,
13 five attacks, and 3 six attacks. The recurrence is apt to be vernal.
Eecovery is the rule in children. The statistics of out-patient depart-
ments are not favorable for determining the mortality. A reliable estimate
is that of the Collective Investigation Committee of the British Medical Asso-
ciation, in which 9 deaths were reported among 439 cases, about 2 per cent.
The paralysis rarely persists. Mental dulness may be present for a time,
but usually passes away ; permanent impairment of the mind is an exceptional
sequence.
Diagnosis. — There are few diseases which present more characteristic feat-
ures, and in a majority of instances the nature of the trouble is recognized at
a glance; but there are several affections in children which may simulate and
be mistaken for it.
(a) Multiple and diffuse cerebral sclerosis. The cases are often mistaken
for ordinary chorea, and have been described in the literature as chorea
spastica.
There are doubtless chronic changes in the cortex. As a rule, the move-
ments are readily distinguishable from those of true chorea, but the simulation
is sometimes very close; the onset in infancy, the impaired intelligence, in-
creased reflexes and in some instances rigidity, and the chronic course of the
disease, separate them sharply from true chorea.
(&) Friedreich's ataxia. Cases of this well-characterized disease were for-
merly classed as chorea. The slow, irregular, incoordinate movements, the
scoliosis, the scanning speech, the early talipes, the nystagmus, and the fam-
ily character of the disease are points which should render the diagnosis easy.
(c) In rare cases the paralytic form of chorea may be mistaken for polio-
myelitis or, when both legs are affected, for paraplegia of spinal origin; but
this can be the case only when the choreic movements are very slight.
(d) Hysteria may simulate chorea minor most closely, and unless there
are other manifestations it may be impossible to make a diagnosis. Most
commonly, however, the movements in the so-called hysterical chorea are
rhythmic and differ entirely from those of ordinary chorea.
(e) As mentioned above, the mental symptoms in maniacal chorea may
1052 .DISEASES OF THE NERVOUS SYSTEM.
mask the true nature of the disease and patients have even been sent to the
asylum.
Treatment. — Abnormally bright, active-minded children belonging to fam-
ilies Avith pronounced neurotic taint should be carefully matched from the ages
of eight to fifteen and not allowed to overtax their mental powers. So fre-
quently in children of this class does the attack of chorea date from the worry
and stress incident to school examinations that the competition for prizes or
places should be emphatically forbidden.
The treatment of the attack consists largely in attention to hygienic meas-
ures, with which alone, in time, a majority of the cases recover. Parents
should be told to scan gently the faults and waywardness of choreic children.
The psychical element, strongly developed in so many eases, is best treated
by quiet and seclusion. The child should be confined to bed in the recumbent
posture, and mental as well as bodily quiet enjoined. In private practice this
is often impossible, but with well-to-do patients the disease is always serious
enough to demand the assistance of a skilled nurse. Toys and dolls should
not be allowed at first, for the child should be kept amused without excitement.
The rest allays the hyper-excitability and reduces to a minimum the possibility
of damage to the valve segments should endocarditis exist. Time and again
have I seen very severe cases which had resisted treatment for weeks outside
a hospital become quiet and the movements subside after two or three days of
absolute rest in bed.
The child should be kept apart from other children and, if possible, from
other members of the family, and should see only those persons directly con-
cerned with the nursing of the case. In the latter period of the disease daily
rubbings may be resorted to with great benefit.
The medical treatment of the disease is unsatisfactory; with the exception
of arsenic, no remedy seems to have any influence in controlling the progress
of the affection. Without any specific action, it certainly does good in many
cases, probably by improving the general nutrition. It is conveniently given
in the form of Fowler's solution, and the good effects are rarel}" seen until
maximum doses are taken. It may be given as Martin originally advised
(1813) ; he began "with five drops and increased one drop every day, until
it might begin to disagree vdth the stomach or bowels." When the dose of
15 minims is reached, it may be continued for a week, and then again in-
creased, if necessary, every day or two, until physiological effects are manifest.
On the occurrence of these the drug should be stopped for three or four days.
The practice of resuming the administration with smaller doses is rarely neces-
sary, as tolerance is usually established and we can begin with the dose which
the child was taking when the s}Tnptoms of saturation occurred. I have fre-
quently given as much as 25 minims three times a day. Usually the signs of
saturation are trivial but plain, but in very rare instances more serious s}Tnp-
toms develop. A fatal arsenical neuritis followed in the case of a child, aged
eight, who took seven drops of Fowler's solution three times a day for ten
days, then stopped for a week, and then took seven drops three times a day for
fourteen days (Gary Gamble, Jr.).
Of other medicines, strychnine, tl>e zinc compounds, nitrate of silver,
bromide of potassium,* belladonna, chloral, and especially cimicifuga, have
been recommended, and may be tried in obstinate cases.
GENERAL AND FUNCTIONAL DISEASES. 1053
For its tonic effect electricity is sometimes useful* but it is not necessary
as a routine treatment. The question of gymnastics is an important one.
Early in the disease, when the movements are active, they are not advisable;
but during convalescence carefully graduated exercises are undoubtedly bene-
ficial. It is not well, however, to send a choreic child to a school gymnasium,
as the stimulus of the other children and the excitement of the romping,
violent play are very prejudicial.
Other points in treatment may be mentioned. It is important to regulate
the bowels and to attend carefully to the digestive functions. For the anaemia
so often present preparations of iron are indicated.
In the severe cases with incessant movements, sleeplessness, dry tongue,
and delirium, the important indication is to procure rest, for which purpose
chloral may be freely given, and, if necessary, morphia. Chloroform inhala-
tions may be necessary to control the intensity of the paroxysms, but the high
rate of mortality in this class of cases illustrates how often our best endeavors
are fruitless. The wet pack is sometimes very soothing and should be tried.
As these patients are apt to sink rapidly into a low typhoid state with heart
weakness, a supporting treatment is required from the outset.
Cases are found now and then which drag on from month to month
without getting either better or worse and resist all modes of treatment.
Change of air and scene is sometimes followeu by rapid improvement, and
in these cases the treatment by rest and seclusion should always be given a
full trial.
In all cases care should be taken to examine the nostrils, and glaring ocular
defects should be properly corrected either by glasses or, if necessary, by
operation.
After the child has recovered from the attack, the parents should be warned
that return of the disease is by no means infrequent, and is particularly liable
to follow overwork at school or debilitating influences of any kind. These
relapses are apt to occur in the spring. Sydenham advised purging in order
to prevent the vernal recurrence of the disease.
IV. OTHER AFFECTIONS DESCRIBED AS CHOREA.
(a) Chorea Major; Pandemic Chorea. — The common name, St. Vitus's
dance, applied to chorea has come to us from the middle ages, when under
the influence of religious fervor there were epidemics characterized by great
excitement, gesticulations, and dancing. For the relief of these symptoms,
when excessive, pilgrimages were made, and in the Rhenish provinces, particu-
larly to the Chapel of St. Vitus in Zebern. Epidemics of this sort occurred
also during the nineteenth century, and descriptions of them among the early
settlers in Kentucky have been given by Robertson and Yandell. It was un-
fortunate that Sydenham applied the term chorea to an affection in children
totally distinct from this chorea major, which is in reality an hysterical mani-
festation under the influence of religious excitement.
(&) Habit Spasm (Habit Chorea) ; /Convulsive Tic (of the French).
Two groups of cases may be recognized under the designation of habit
spasm — one in which there are simply localized spasmodic movements, and
the other in which, in addition to this, there are explosive utterances and
1054 DISEASES OF THE NERVOUS SYSTEM.
psychical symptoms, a condition to which French writers have given the name
tic convulsif.
(1) Habit Spasm. — This is found chiefly in childhood, most frequently
in girls from seven to fourteen years of age (Mitchell). In its simplest form
there is a sudden, quick contraction of certain of the facial muscles, such as
rapid winking or drawing of the mouth to one side, or the neck muscles are
■ involved and there are unilateral movements of the head. The head is given
a sudden, quick shake, and at the same time the eyes wink. A not infrequent
form is the shrugging of one shoulder. The grimace or movement is repeated
at irregular intervals, and is much aggravated by emotion. A short inspira-
tory snifE is not an uncommon symptom. The cases are found most frequently
in children who are " out of sorts,'^ or who have been growing rapidly, or who
have inherited a tendency to neurotic disorders. Allied to or associated with
this are some of the curious tricks of children. A boy at my clinic was in the
habit every few moments of putting the middle finger into the mouth, biting
it, and at the same time pressing his nose with the forefinger. Hartley Cole-
ridge is said to have had a somewhat similar trick, only he bit his arm. In
all these cases the habits of the child should be examined carefully, the nose
and vault of the pharynx thoroughly inspected, and the eyes accurately tested.
As a rule the condition is transient, and after persisting for a few months
or longer gradually disappears. Occasionally a local spasm persists — twitching
of the eyelids, or the facial grimace.
(2) Impulsive Tic (Gilles de la Toueette's Disease). — This remark-
able affection, often mistaken for chorea, more frequently for habit spasm, ia
really a psychosis allied to hysteria, though in certain of its aspects it has
the features of monomania. The disease begins, as a rule, in young children,
occurring as early as the sixth year, though it may develop after puberty.
There is usually a markedly neurotic family history. The special features of
the complaint are:
{a) Involuntary muscular movements, usually affecting the facial or
brachial muscles, but in aggravated cases all the muscles of the body may
be involved and the movements may be extremely irregular and violent.
(&) Explosive utterances, which may resemble a bark or an inarticulate
cry. A word heard may be mimicked at once and repeated over and over
again, usually with the involuntary movements. To this the term ecliolalia
has been applied. A much more distressing disturbance in these cases is
coprolalia, or the use of bad language. A child of eight or ten may shock its
mother and friends by constantly using the word damn when making the
involuntary movements, or by uttering all sorts of obscene words. Occasion-
ally actions are mimicked — ecJioTiinesis.
(c) Associated with some of these cases are curious mental disturbances;
the patient becomes the subject of a form of obsession or a fixed idea. In
other cases the fixed idea takes the form of the impulse to touch objects, or it
is a fixed idea about words — onomatomania — or the patient may feel compelled
to count a number of times before doing certain actions — arithmomania.
The disease is well marked and readily distinguished from ordinary chorea.
The movements have a larger range and are explosive in character. Tourette
regards the coprolalia as the most distinctive feature of the disease. The
prognosis is doubtfuL I have, however, known recovery to follow.
GENERAL AND FUNCTIONAL DLSEASES. 1055
(c) Saltatory Spasm {Laiah; Myriachlt; Jumpers). — Bamberger has de-
scribed a disease in which when the patient attempted to stand there were
strong contractions in the leg muscles, which caused a jumping or spring-
ing motion. This occurs only when the patient attempts to stand. The
affection has occurred in both men and women, more frequently in the
former, and the subjects have usually shown marked neurotic tendencies.
In many cases the condition has been transitory; in others it has persisted
for years. Eemarkable affections similar to this in certain points occur
as a sort of epidemic neurosis. One of the most striking of these occurs
among the " jumping Frenchmen " of Maine and Canada. As described
by Beard and Thornton, the subjects are liable on any sudden emotion
to jump violently and utter a loud cry or sound, and will obey any com-
mand or imitate any action without regard to its nature. The condition of
echolalia is present in a marked degree. The " jumping " prevails in certain
families.
A very similar disease prevails in parts of Eussia and in Java and Borneo,
where it is known by the names of myriachit and latah, the chief feature of
which is mimicry by the patient of everything he sees or hears.
(d) Chronic Chorea {Huntington's Chorea). — An affection characterized
by irregular movements, disturbance of speech, and gradual dementia. It
is frequently hereditary. Irving W. Lyon described it in 1863 as chronic
hereditary chorea and traced the disease through five generations. Hunting-
ton, of Pomeroy, Ohio, at the time a practitioner on Long Island, gave, in
1873, in three brief paragraphs the salient points in connection with the
disease — namely, the hereditary nature, the association with psychical troubles,
and the late onset — between the thirtieth and fortieth years. The disease
seems common in the United States, and many cases have been reported by
Clarence King, Sinkler, and others. I have seen it in two Maryland fam-
ilies within a few years. Under the term chronic chorea may be grouped the
hereditary form and the cases which come on without family disposition,
either at middle life or, more commonly, in the aged — senile chorea. It is
doubtful whether the cases in children with chronic choreiform movements,
often with mental weakness and spastic condition of the legs, should go into
this category.
The hereditary character of the disease is very striking ; it has been traced
through four or five generations. Huntington's father and grandfather, also
physicians, had treated the disease in the family which he described. Osborn,
of East Hampton, L. I., writes (Jan. 28th, 1898) that the disease still con-
tinues to recur in certain families described by Huntington, as it has done,
so it is said, for fully two centuries. An identical affection occurs without
any hereditary disposition. The age of onset is late, rarely before the thirtieth
or the thirty- fifth year.
The symptoms are very characteristic. The irregular movements are usu-
ally first seen in the hands, and the patient has slight difficulty in performing
delicate manipulations or in writing. When well established the movements
are disorderly, irregular, incoordinate rather than choreic, and have not the
sharp, brusque motion of Sydenham's chorea. In the face there are slow,
involuntary grimaces. In a well-developed case the gait is irregular, swaying,
and somewhat like that of a drunken man. The speech is slow and difficult.
1056 DISEASES OF THE NERVOUS SYSTEM.
the syllables are badh' pronounced and indistinct;, biit not definitely staccato.
The mental impairment leads finally to dementia.
Very few autopsies have been made. Xo characteristic lesions have been
found. Atrophy of the convolutions, chronic meningo-encephalitis, and vas-
cular changes have usually been present, the conditions which one would ex-
pect to find in chronic dementia. The study of two cases by Facklan (Arch,
f. Psychiatric^ 30) confirms the view expressed in former editions that the
disease is a chronic meningo-encephalitis with atrophy of the convolutions.
The cord and peripheral nerves he foimd perfectly healthy. The affection is
evidently a neuro-degenerative disorder, and has no connection with the sim-
ple chorea of childhood.
(e) Rhythmic or Hysterical Chorea. — This is readily recognized by the
rhjrthmieal character of the movements. It may affect the muscles of the
abdomen, producing the salaam convulsion, or involve the sterno-mastoid,
producing a rhythmical movement of the head, or the psoas, or any group of
muscles. In its orderly rhythm it resembles the canine chorea.
V. INFANTILE CONVUIiSIONS (Eclampsia).
Convulsive seizures similar to those of epilepsy are not infrequent in chil-
dren and in adults. The fit may indeed be identical with epilepsy, from which
the condition differs in that when the cause is removed there is no tendency
for the fits to recur. Occasionally, however, the convulsions in children con-
tinue and develop into true epilepsy.
Etiology. — A convulsion in a child may be due to many causes, all of which
lead to an unstable condition of the nerve-centres, permitting sudden, ex-
cessive, and temjDorary nervous discharges. The following are the most impor-
tant of them :
(1) DehiUty, resulting usually from gastro-intestinal disturbance. Con-
vulsions frequently supervene toward the close of an attack of entero-colitis
and recur, sometimes proving fatal. Morris J. Lewis has shown that the
death-rate in children from eclampsia rises steadily with that of gastro-intes-
tinal disorders.
(2) Peripheral irritation. Dentition alone is rarely a cause of convul-
sions, but is often one of several factors in a feeble, unhealthy infant. The
greatest mortality from convulsions is during the first six months, before the
teeth have really cut through the gums. Other irritative causes are the over-
loading of the stomach with indigestible food. It has been suggested that
some of these cases are toxic, o"\ving to the absorption of poisonous ptomaines.
Worms, to which convulsions are so frequently attributed, probably have little
influence. Among other sources possible are phimosis and otitis.
(3) Rickets. The observation of Sir William Jenner upon the associa-
tion of rickets and convulsions has been amply confirmed. The spasms may
be laryngeal, the so-called child-crowing, which, though convulsive in nature,
can scarcely be reckoned under eclampsia. The influence of this condition is
more apparent in Europe than in the United States, although rickets is a com-
mon disease, particularly among the colored people. Spasms, local or gen-
eral, in rickets are probably associated with the condition of debility and mal-
nutrition and with cranio-tabes.
GENERAL AND FUNCTIONAL DISEASES. 1057
(4) Fever. In young children the onset of the infectious diseases is fre-
quently with convulsions, which often take the place of a chill in the adult.
It is not known upon what they depend. Scarlet fever, measles, and pneu-
monia are most often preceded by convulsions.
(.5) Congestion of the brain. That extreme engorgement of the blood-
vessels may produce convulsions is shown by their occasional occurrence in
severe whooping-cough, but their rarity in this disease really indicates how
small a part mechanical congestion plays in the production of fits.
(6) Severe convulsions usher in or accompany many of the serious dis-
eases of the nervous system in children. In more than 50 per cent of the cases
of infantile hemiplegia the affection follows severe convulsions. They less
frequently precede a spinal paralysis. They occur with meningitis, tubercu-
lous or simple, and with tumors and other lesions of the brain.
And, lastly, convulsions may occur immediately after birth and persist
for weeks or months. In such instances there has probably been meningeal
haemorrhage or serious injury to the cortex.
The most important question is the relation of convulsions in children
to true epilepsy. In Gowers' figures of 1,450 cases of epilepsy, the attacks
began in 180 during the first three years of life. Of 460 cases of epilepsy
in children which I have analyzed, in 187 the fits began within the first three
years. Of the total list the greatest number, 74, was in the first year. In
nearly all these instances there was no interruption in the convulsions. That
convulsions in early infancy are necessarily followed by epilepsy in after life
is certainly a mistake.
Symptoms. — The attack m.a,j come on suddenly without any warning ; more
commonly it is preceded by a stage of restlessness, accompanied by twitching
and perhaps grinding of the teeth. It is rarely so complete in its stages as
true epilepsy. The spasm begins usually in the hands, most commonly in the
right hand. The eyes are fixed and staring or are rolled up. The body be-
comes stiff and breathing is suspended for a moment or two by tonic spasm
of the respiratory muscles, in consequence of which the face becomes congested.
Clonic convulsions follow, the eyes are rolled about, the hands and arms twitch,
or are fiexed and extended in rhythmical movements, the face is contorted,
and the head is retracted. The attack gradually subsides and the child sleeps
or passes into a state of stupor. Following indigestion the attack may be
single, but in rickets and intestinal disorders it is apt to be repeated. Some-
times the attacks follow each other with great rapidity, so that the child never
rouses but dies in a deep coma. If the convulsion has been limited chiefiy to
one side there may be slight paresis after recovery, or in instances in which
the convulsions usher in infantile hemiplegia, when the child arouses, one side
is completely paralyzed. During the fit the temperature is often raised.
Death rarely occurs from the convulsion itself, except in debilitated children or
when the attacks recur with great frequency. In the so-called hydrocephaloid
state in connection with protracted diarrhoea convulsions may close the scene.
Diagnosis. — Coming on when the subject is in full health, the attack is
probably due either to an overloaded stomach, to some peripheral irritation, or
occasionally to trauma. Setting in with high fever and vomiting, it may
indicate the onset of an exanthem, or occasionally be the primary symptom of
encephalitis, or whatever the condition is which causes infantile hemiplegia,
68
1058 DISEASES OF THE NERVOUS SYSTEM.
WTien the attack is associated with debility and with rickets the diagnosis is
easily made. The carpopedal spasms and pseudo-paralytic rigidity which are
often associated with rickets, larjTigismus stridulus, and the hydrocephaloid
state are usually confined to the hands and arms and are intermittent and usu-
ally tonic. The convulsions associated with tumor or those which follow
infantile hemiplegia are usually at first Jacksonian in character. After the
second year convulsive seizures which come on irregularly without apparent
cause and recur while the child is apparently in good health, are likely to
prove true epilepsy.
Prognosis. — Convulsions play an important part in infantile mortality.
In Morris J. Lems's table of deaths in children under ten, 8.5 per cent were
ascribed to convulsions. West states that 22.35 per cent of deaths under one
year are caused by convulsions, but this is too high an estimate for America.
In chronic diarrhoea convulsions are usually of ill omen. Those ushering in
fevers are rarely serious, and the same may be said of the fits associated with
indigestion and peripheral irritation.
Treatment. — Every source of irritation should be removed. If associated
with indigestible food, a prompt emetic should be given, followed by an enema.
The teeth should be examined, and if the gum is swollen, hot, and tense, it
may be lanced ; but never if it looks normal. When seen at first, if the parox-
ysm is severe, no time should be lost by giving a hot bath, but chloroform
should be given at once, and repeated if necessary, A child is so readily put
under chloroform and with such a small quantity that this procedure is quite
harmless and saves much valuable time. The practice is almost universal of
putting the child into a warm bath, and if there is fever the head may be
douched with cold water. The temperature of the bath should not be above
95° or 96°. The very hot bath is not suitable, particularly if the fits are due
to indigestion. After the attack an ice-cap may be placed upon the head. If
there is much irritability, particularly in rickets and in severe diarrhoea, small
doses of opium will be found efficacious. Wlien the convulsions recur after the
child comes from under the influence of chloroform it is best to place it rapidly
under the influence of opium, wliich may be given as morphia h}'podermically,
in doses of from one-twenty-fifth to one-thirtieth of a grain for a child of one
year. Other remedies recommended are chloral by enema, in 5-grain doses, and
nitrite of am}^. After the attack has passed the bromides are useful, of which
5 to 8 grains may be given in a day to a child a year old. Eecurring convul-
sions, particularly if they come . on without special cause, should receive the
most thorough and careful treatment with bromides. When associated with-
rickets the treatment should be directed to improving the general condition.
VI. EPILEPSY.
Definition. — An affection of the nervous system characterized by attacks
of unconsciousness, with or without convulsions.
The transient loss of consciousness without convulsive seizures is known
as, petit mal; the loss of consciousness with general convulsive seizures is known
as grand mal. Localized convulsions, occurring usually without loss of con-
sciousness, are kno-mi as epileptiform, or more frequently as Jacksonian or
eortical epilepsy.
GENERAL AND FUNCTIONAL DISEASES. 1059
Etiology. — Age. — In a large proportion of all cases the disease begins be-
fore puberty. Of the 1/150 cases observed hj Gowers, in 422 the disease began
before the tenth year, and three-fourths of the cases began before the twen-
tieth year. Of 460 cases of epilepsy in children which I have analyzed the
age of onset in 427 was- as follows: First year, 74; second year, 62; third
year, 51; fourth year, 24; fifth year, 17; sixth year, 18; seventh year, 19;
eighth year, 23 ; ninth year, 17 ; tenth year, 27 ; eleventh year, 17 ; twelfth year,
18; thirteenth year, 15; fourteenth year, 21; fifteenth year, 34. Arranged
in hemidecades the figures are as follows : From the first to the fifth year, 229 ;
from the fifth to the tenth year, 104; from the tenth to the fifteenth year, 95.
These figures illustrate in a striking manner the early onset of the disease in
a large proportion of the cases. It is well always to be suspicious of epilepsy
developing in the adult, for in a majority of such cases the convulsions are' due
to a local lesion.
Sex. — No special influence appears to be discoverable in this relation, cer-
tainly not in children. Of 433 cases in my tables, 232 were males and 203
were females, showing a slight predominance of the male sex. After puberty
unquestionably, if a large number of cases are taken, the males are in excess.
The figures of Sieveking and Eeynolds would tend to show that the disease
is rather more prevalent in females than in males.
Heredity. — Much stress has been laid upon this by many authors as an
important predisposing cause, and the statistics collected give from 9 to over
40 per cent. Gowers gives 35 per cent for his cases, which have special value
apart from other statistics embracing large numbers of epileptics in that they
were collected by him in his own practice. In our figures it appears to play a
minor role. In the Infirmary list there were only 31 cases in which there was
a history of marked neurotic taint, and only 3 in which the mother herself
had been epileptic. In the Elwyn cases, as might be expected, the percentage
is larger. Of the 126 there was in 32 a family history of nervous derangement
of some sort, either paralysis, epilepsy, marked hysteria, or insanity. It is
interesting to note that in this group, in which the question of heredity is
carefully looked into, there were only two in which the mother had had
epilepsy, and not one in which the father had been affected. Indeed, I
was not a little surprised to find in the list of my cases that hereditary
influences played so small a part. I have heard this opinion expressed by
certain French physicians, notably Marie, who also in writing upon the
question takes strong grounds against heredity as an important factor in
epilepsy.
While, then, it may be said that direct inheritance is comparatively un-
common, yet the children of neurotic families in which neuralgia, insanity,
and hysteria prevail are more liable to fall victims to the disease.
Chronic alcoholism in the parents is regarded by many as a potent pre-
disposing factor in the production of epilepsy. Echeverria has analyzed 572
cases bearing upon this point and divided them into three classes, of which
257 cases could be traced directly to alcohol as a cause; 126 cases in which
there were associated conditions, such as syphilis and traumatism; 189 cases
in which the alcoholism was probably the result of the epilepsy. Figures
equally strong are given by Martin, who in 150 insane epileptics found 83
with a marked history of parental intemperance. Of the 126 Elwyn cases, in
1060 DISEASES OF THE NERVOUS SYSTEM.
which the family histor}^ on this point was carefully investigated, a definite
statement was found in only 4 of the cases.
Syphilis. — This in the parents is probably less a predisposing than an
actual cause of epilepsy, which is the direct outcome of local cerebral mani-
festations. There is no reason for recognizing a special form of syphilitic
epilepsy. On the other hand, convulsive seizures due to acquired syphilitic
disease of the brain are very common.
Poisoxs. — Alcohol. — Severe epileptic convulsions may occur in steady
drinkers.
Of exciting causes fright is believed to be important, but is less so, I
think, than is usually stated. Trauma is present in a certain number of in-
stances. An important group depends upon a local disease of the brain exist-
ing from childhood, as seen in the post-hemiplegic epilepsy. Occasionally cases
follow the infectious fevers. Masturbation has been stated to be a special
cause, but its influence is probably overrated. A large group of convulsive
seizures allied to epilepsy are due to some toxic agent, as in lead poisoning
and in uraemia.
Eeflex Causes. — Dentition and worms, the irritation of a cicatrix, some
local affection, such as adherent prepuce, or a foreign body in the ear or the
nose, are given as causes. In many of these cases the fits cease after the re-
moval of the cause, so that there can be no question of the association between
the two. In others the attacks persist. Genuine cases of reflex epilepsy are,
I believe, rare. A remarkable instance of it occurred at the Philadelphia
Infirmary for Diseases of the ]SI"ervous System in the case of a man with a
testis in the inguinal canal, pressure upon which would cause a typical fit.
Eemoval of the organ was followed by cure.
Cardio-vascular epilepsy is usually a manifestation of advanced arterio-
sclerosis, and is associated with slow pulse (see Stokes- Adams Disease).
There may be palpitation and uneasy sensations about the heart prior to the
attack. The passage of a gall-stone or the removal of pleuritic fluid may
induce a fit. Indigestion and gastric troubles are extremely common in epi-
lepsy, and in many instances the eating of indigestible articles seems to pre-
cipitate an attack. And lastly, epileptic seizures may occur in old people
without obvious cause.
Symptoms. — (1) Grand Mal. — Preceding the fits there is usually a local-
ized sensation, kno^vn as an aura, in some part of the body. This may be
somatic, in which the feeling comes from some particular region in the periph-
ery, as from the finger or hand, or is a sensation felt in the stomach or about
the heart. The peripheral sensations preceding the fit are of great value,
particularly those in which the aura always occurs in a definite region, as in
one finger or toe. It is the equivalent of the signal symptom in a fit from
a brain tumor. The varieties of these sensations are numerous. The epigas-
tric sensations are most common. In these the patient complains of an uneasy
sensation in the epigastrium or distress in the intestines, or the sensation may
not be unlike that of heart-burn and may be associated with palpitation.
These groups are sometimes kno^vn as pneumogastric aurse or warnings.
Of psychical aurae one of the most common, as described by Hughlings
Jackson, is the vague, dreamy state, a sensation of strangeness or sometimes
of terror. The aurse may be associated with special senses; of these the most
GENERAL AND FUNCTIONAL DISEASES. 1061
common are the visual, consisting of flashes of light or sensations of color;
less commonly, distinct objects are seen. The auditory aurae consist of noises
in the ear, odd sounds, musical tones, or occasionally voices. Olfactory and
gustatory aurge, unpleasant tastes and odors, are rare.
Occasionally the fit may be preceded not by an aura, but by certain move-
ments ; the patient may turn round rapidly or run with great speed for a few
minutes, the so-called epilepsia procursiva. In one of the Elwyn cases the lad
stood on his toes and twirled with extraordinary rapidity, so that his features
were scarcely recognizable. At the onset of the attack the patient may give a
loud scream or yell, the so-called epileptic cry. The patient drops as if shot,
making no effort to guard the fall. In consequence of this epileptics fre-
quently injure themselves, cutting the face or head or burning themselves. In
the attack, as described by Hippocrates, '^the patient loses his speech and
chokes, and foam issues from the mouth, the teeth are fixed, the hands are
contracted, the eyes distorted, he becomes insensible, and in some cases the
bowels are affected. And these symptoms occur sometimes on the left side,
sometimes on the right, and sometimes on both." The fit may be described
in three stages:
(a) Tonic Spasm. — The head is drawn back or to the right, and the jaws
are fixed. The hands are clinched and the legs extended. This tonic contrac-
tion affects the muscles of the chest, so that respiration is impeded and the
initial pallor of the face changes to a dusky or livid hue. The muscles of
the two sides are unequally affected, so that the head and neck are rotated or
the spine is twisted. The arms are usually flexed at the elbows, the hand at the
wrist, and the fingers are tightly clinched in the palm. This stage lasts only
a few seconds, and then the clonic stage begins.
(&) Clonic stage. The muscular contractions become intermittent; at
first tremulous or vibratory, they gradually become more rapid and the
limbs are jerked and tossed about violently. The muscles of the face are in
constant clonic spasm, the eyes roll, the eyelids are opened and closed con-
vulsively. The movements of the muscles of the jaw are very forcible and
strong, and it is at this time that the tongue is apt to be caught between the
teeth and lacerated. The cyanosis, marked at the end of the tonic stage, grad-
ually lessens. A frothy saliva, which may be blood-stained, escapes from the
mouth. The faeces and urine may be discharged involuntarily. The duration
of this stage is variable. It rarely lasts more than one or two minutes. The
contractions become less violent and the patient gradually sinks into the con-
dition of coma.
(c) Coma. The breathing is noisy or even stertorous, the face congested,
but no longer intensely cyanotic. The limbs are relaxed and the unconscious-
ness is profound. After a variable time the patient can be aroused, but if
left alone he sleeps for some hours and then awakes, complaining only of
slight headache or mental confusion. If the attack has been severe petechial
haemorrhage may be scattered over the neck and chest. In the case of a
young man in good health in a severe convulsion both sub-conjunctival
spaces were entirely filled with blood, and free blood oozed from them (Walter
James). Haemoptysis is a rare sequel.
Status Epilepticus. — This is the climax of the disease, in which attacks
occur in rapid succession, and the patient does not recover consciousness. The
1062 DISEASES OF THE NERVOUS SYSTEM.
pulse, respiration, and temperature rise in the attack. It is a serious condi-
tion, and often proves fatal.
After the attack the reflexes are sometimes absent; more frequently they
are increased and the ankle clonus can usually be obtained. The state of the
urine is variable, particularly as regards the solids. The quantity is usually
increased after the attack, and albumin is not infrequently present.
Post-epileptic symptoms are of great importance. The patient may be in
a trance-like condition, in which he performs actions of which subsequently
he has no recollection. More serious are the attacks of mania, in which the
patient is often dangerous and sometimes homicidal. It is held by good
authorities that an outbreak of mania may be substituted for the fit. And,
lastly, the mental condition of an epileptic patient is often seriously impaired,
and profound defects are common.
Paralysis, which rarely follows the epileptic fit, is usually hemiplegic and
transient. Slight disturbances of speech also may occur; in some instances,
forms of sensory aphasia.
The attacks may occur at night, and a person may be epileptic for years
without knowing it. As Trousseau truly remarks, when a person tells us that
in the night he has incontinence of urine and awakes in the morning with
headache and mental confusion, and complains of difficulty in speech owing to
the fact that he has bitten his tongue, if also there are purpuric spots on the
skin of the face and neck, the probability is very strong indeed that he is
subject to nocturnal epilepsy.
(2) Petit Mal. — This is epilepsy without the convulsions. The attack
consists of transient unconsciousness, which may come on at any time, accom-
panied or unaccompanied by a feeling of faintness and vertigo. Suddenly, for
example, at the dinner table, the subject stops talking and eating, the eyes
become fixed, and the face slightly pale. Anything which may have been in
the hand is usually dropped. In a moment or two consciousness is regained
and the patient resumes conversation as if nothing had happened. In other
instances there is slight ineoherency or the patient performs some almost
automatic action. He may begin to undress himself and on returning to con-
sciousness find that he has partially disrobed. He may rub his beard or face,
or may spit about in a careless way. In other attacks the patient may fall
without convulsive seizures. A definite aura is rare. Though transient, un-
consciousness and giddiness are the most constant manifestations of petit mal;
there are many other equivalent manifestations, such as sudden jerkings in the
limbs, sudden tremor, or a sudden visual sensation. Gowers mentions no less
than seventeen different manifestations of petit mal. Occasionally there are
cases in which the patient has a sensation of losing his breath and may even
get red in the face. I have seen such attacks also in children.
After the attack the patient may be dazed for a few seconds and perform
certain automatic actions, which may seem to be volitional. As mentioned,
undressing is a common action, but all sorts of odd actions may be performed,
some of which are awkward or even serious. One of my patients after an
attack was in the habit of tearing anything he could lay hands on, particularly
books. Violent actions have been committed and assaults made, frequently
giving rise to questions which come before the courts. This condition has been
termed masked epilepsy, or epilepsia larvata.
GENERAL AND FUNCTIONAL DISEASES. 1063
In a majority of the cases of petit mal convulsions finally occur, at first
slight, but ultimately the grand mal becomes well developed, and the attacks
may then alternate.
(3) Jacksonian Epilepsy. — This is also known as cortical, symptomatic,
or partial epilepsy. It is distinguished from the ordinary epilepsy by the
important fact that consciousness is retained or is lost late. The attacks are
usually the result of irritative lesions in the motor zone, though there are
probably also sensory equivalents of this motor form. In a typical attack the
spasm begins in a limited muscle group of the face, arm, or leg. The zygomatic
muscles, for instance, or the thumb may twitch, or the toes may first be moved.
Prior to the twitching the patient may feel a sensation of numbness or tingling
in the part affected. The spasm extends and may involve the muscles of one
limb only or of the face. The patient is conscious throughout and watches,
often with interest, the march of the spasm.
The onset may be slow, and, as in a case which I have reported, there may
be time for the patient to place a pillow on the floor, so as to be as com-
fortable as possible during the attack. The spasms may be localized for years,
but there is a great risk that the partial epilepsy may become general. The
condition is due, as a rule, to an irritative lesion in the motor zone. Thus of
107 cases analyzed by Eoland, there were 48 of tumor, 21 instances of inflam-
matory softening, 14 instances of acute and chronic meningitis, and 8 cases
of trauma. The remaining instances were due to haemorrhage or abscess, or
were associated with, sclerosis cerebri. Two other conditions may be mentioned,
which may cause typical Jacksonian epilepsy — namely, uraemia and progressive
paralysis of the insane. A considerable number of the cases of Jacksonian
epilepsy are found in children following hemiplegia, the so-called post-hemi-
plegic epilepsy. The convulsions usually begin on the aifected side, either in
the arm or leg, and the fit may be unilateral and without loss of consciousness.
Ultimately they become more severe and general.
Diagnosis. — In major epilepsy the suddenness of the attack, the abrupt loss
of consciousness, the order of the tonic and clonic spasm, and the relaxation
of the sphincters at the height of the attack are distinctive features. The
convulsive seizures due to uraemia are epileptic in character and usually readily
recognized by the existence of greatly increased tension and the condition of
the urine. Practically in young adults hysteria causes the greatest difficulty,
and may closely simulate true epilepsy. The table on page 1064, from Gowers'
work, draws clearly the chief differences between them.
Recurring epileptic seizures in a person over thirty who has not had pre-
vious attacks is always suggestive of organic disease. According to H. C.
Wood, whose opinion is supported by that of Fournier, in 9 cases out of 10
the condition is due to syphilis.
Petit mal must be distinguished from attacks of syncope, and the vertigo
of Meniere's disease, of a cardiac lesion, and of indigestion. In these cases
there is no actual loss of consciousness, which forms a characteristic though not
an invariable feature of petit mal.
JacTcsonian epilepsy has features so distinctive and peculiar that it is at
once recognized. It is, however, by no means easy always to determine upon
what the spasm depends. Irritation in the motor centres may be due to a great
variety of causes, among which tumors and localized meningo-encephalitis are
1064
DISEASES OF THE NERVOUS SYSTEM.
the most frequent; but it must not be forgotten that in uraemia localized
epilepsy may occur. The most typical Jacksonian spasms also are not infre-
quent in general paresis of the insane.
Epileptic.
Hystkroid.
Apparent cause . . .
Warning
Onset
Scream
Convulsion
Biting
Micturition
Defecation
Talking
Duration
Restraint necessary
Termination
none.
any, but especially unilateral
or epigastric aurse.
always sudden.
at onset.
rigidity followed by "jerk-
ing," rarely rigidity alone.
tongue.
frequent.
occasional,
never.
a few minutes.
to prevent accident,
spontaneous.
emotion.
palpitation, malaise, choking, bi-
lateral foot aura.
often gradual.
during course.
rigidity or " struggling," throwing
about of limbs or head, arching
of back.
lips, hands, or other people and
things.
never.
never.
frequent.
more than ten minutes, often
much longer.
to control violence.
spontaneous or induced (water,
etc.).
Prognosis. — This may be given to-day in the words of Hippocrates : " The
prognosis in epilepsy is unfavorable when the disease is congenital, and when
it endures to manhood, and when it occurs in a grown person without any
previous cause. . . . The cure may be attempted in young persons, but not
in old." W. A. Turner concludes from recent studies that of cases beginning
under ten years few are arrested, whereas of those beginning at puberty the
opposite is true. Cases beginning between the twentieth and thirty-fifth years
give few arrests. After thirty-five the outlook is good.
Death during the fit rarely occurs, but it may happen if the patient falls
into the water or if the fit comes on while he is eating. Occasionally the fits
seem to stop spontaneously. This is particularly the case in the epilepsy in
children which has followed the convulsions of teething or of the fevers. Fre-
quency of the attacks and marked mental disturbance are unfavorable indi-
cations. Hereditary predisposition is apparently of no moment in the prog-
nosis. The outlook is better in males than in females. The post-hemiplegic
epilepsy is rarely arrested. Of the cases coming on in adults, those due to
syphilis and to local affections of the brain allow a more favorable prognosis.
Treatment. — General. — In the case of children the parents should be
made to understand from the outset that epilepsy in the great majority of
cases is an incurable affection, so that the disease may interfere as little as
possible with the education of the child. The subjects need firm but kind
treatment. Indulgence and yielding to caprices and whims are followed by
weakening of the moral control, which is so necessajy in these cases. The
disease does not incapacitate a person for all occupation. It is much better
for epileptics to have some definite pursuit. There are many instances in
which they have been persons of extraordinary mental and bodily vigor, as,
for example, Julius Csesar and Napoleon. One of the most distressing features
in epilepsy is the gradual mental impairment which follows in a certain num-
ber of cases. If such patients become extremely irritable or show signs of
GENERAL AND FUNCTIONAL DISEASES. 1065
violence they should be placed under supervision in an asylum. Marriage
should be forbidden to epileptics. During the attack a cork or bit of rubber
should be placed between the teeth and the clothes should be loosened. The
patient should be in the recumbent posture. As the attack usually passes off
with rapidity, no special treatment is necessary, but in cases in which the
convulsion is prolonged a few whiffs of chloroform or nitrite of amyl or a
hypodermic of a quarter of a grain of morphia may be given.
Dietetic. — The old authors laid great stress upon regimen in epilepsy.
The important point is to give the patient a light diet at fixed hours, and
on no account to permit overloading of the stomach. Meat should not be
given more than once a day. There are cases in which animal food seems
injurious. A strict vegetable diet has been warmly recommended. The patient
should not go to sleep until the completion of gastric digestion.
Medicinal. — The bromides are the only remedies which have a special
influence upon the disease. Either the sodium or potassium salt may be given.
Sodium bromide is probably less irritating and is better borne for a long period.
It may be given in milk, in which it is scarcely tasted. In all instances the
dilution should be considerable. In adults it is well taken in soda water or in
some mineral water. The dose for an adult should be from half a drachm
to a drachm and a half daily. As Seguin recommends, it is often best to give
but a single dose daily, about four to six hours before the attacks are most
likely to occur. For instance, in the case of nocturnal epilepsy a drachm
should be given an hour or two after the evening meal. If the attack occurs
early in the morning, the patient should take a full dose when he awakes.
When given three times a day it is less disturbing after meals. Each case
should be carefully studied to determine how much bromide should be used.
The individual susceptibility varies and some patients require more than others.
Fortunately, children take the drug well and stand proportionately larger doses
than adults. Saturation is indicated by certain unpleasant effects, particu-
larly drowsiness, mental torpor, and gastric and cardiac distress. Loss of
palate reflex is one of the earliest indications that the system is under the
influence of the bromides, and is a condition which should be attained. A
very unpleasant feature is the development of acne, which, however, is no indi-
cation of bromism. Seguin states that the tendency to this is much dimin-
ished by giving the drug largely diluted in alkaline waters and administering
from time to time full doses of arsenic. To be effectual the treatment should
be continued for a prolonged period and the cases should be incessantly watched
in order to prevent bromism. The medicine should be continued for at least
two years after the cessation of the fits; indeed, Seguin recommends that the
reduction of the bromides should not be begun until the patient has been
three years without any manifestations. Written directions should be given
to the mother or to the friends of the patient, and he should not himself be
held responsible for the administration of the medicine. A book should be
provided in which the daily number of attacks and the amount of medicine
taken should be noted. The addition of belladonna to the bromide is warmly
recommended by Black, of Glasgow. In very obstinate cases Fleehsig uses
opium, 5 or 6 grains, in three doses daily ; then at the end of six weeks opium
is stopped and the bromides in large amounts, 75 to 100 grains daily, are used
for two months.
G9
1066 DISEASES OF THE NERVOUS SYSTEM.
Among other remedies which have been recommended as controlling epi-
lepsj are chloral, cannabis indica, zinc, nitroglycerin, and borax. Nitrogly-
cerin is sometimes advantageous in petit mal, but is not of much service in
the major form. To be beneficial it must be given in full doses, from 2 to 5
minims of the 1-per-cent solution, and increased until the physiological effects
are produced. Counter- irritation is rarely advisable. When the aura is very
definite and constant in its onset, as from the hand or from the toe, a blister
about the part or a ligature tightly applied may stop the oncoming fit. In
children, care should be taken that there is no source of peripheral irritation.
In boys, adherent prepuce may occasionally be the cause. The irritation of
teething, the presence of worms, and foreign bodies in the ears or nose have
been associated with epileptic seizures.
The subjects of a chronic and, in most cases, a hopelessly incurable disease,
epileptic patients form no small portion of the unfortunate victims of charla-
tans and quacks, who prescribe to-day, as in the time of the father of medicine,
" purifications and spells and other illiberal practices of like kind."
Surgical. — In Jacksonian epilepsy the propriety of surgical interference
is universally granted. It is questionable, however, whether in the epilepsy
following hemiplegia, considering the anatomical condition, it is likely to be
of any benefit. In idiopathic epilepsy, when the fit starts in a certain region
— ^the thumb, for instance — and the signal symptom is invariable, the centre
controlling this part may be removed. This procedure has been practised by
Macewen, Horsley, Keen, and others, but time alone can determine its value.
The traumatic epilepsy, in which the fit follows fracture, is much more hopeful.
The operation, per se, appears in some cases to have a curative effect. Thus
of 50 cases of trephining for epilepsy in which nothing abnormal was found to
account for the symptoms, 25 were reported as cured and 18 as improved. The
operations have not been always on the skull, and White has collected an inter-
esting series in which various surgical procedures have been resorted to, often
with curative effect, such as ligation of the carotid artery, castration, tracheot-
omy, excision of the superior cervical ganglia, incision of the scalp, circum-
cision, etc.
The feasibility of State colonization of epileptics on a self-supporting basis
has been demonstrated by the success of the Craig Colony at Sonyea, New
York.
VII. MIGRAINE (Hemicrania ; Sick Headache).
Definition. — A paroxysmal affection characterized by severe headache, usu-
ally unilateral, and often associated with disorders of vision.
Etiology. — The disease is frequently hereditary and has occurred through
several generations. Women and the members of neurotic families are most
frequently attacked. It is an affection from which many distinguished men
have suffered and have left on record an account of the disease, notably the
astronomer Airy. Edward Liveing's work is the standard authority upon
which most of the subsequent articles have been based. A gouty or rheumatic
taint is present in many instances. Sinkler has called special attention to the
frequency of reflex causes. Migraine has long been known to be associated with
uterine and menstrual disorders. Nutritive disturbances are common, and
GENERAL AND FUNCTIONAL DISEASES. 1067
attempts have been made by Haig and others to associate the attacks with
disturbed uric-acid output. Certainly the amount of uric acid excreted just
prior to and during an attack is reduced. Others regard the disease as a
toxaemia from disordered intestinal digestion. Many of the headaches from
eye-strain are of the hemicranial type; but it is impossible to regard this,
as Gould and others would do, as the sole factor. Cases have been described
in connection with adenoid growths in the pharynx, and particularly with
abnormal conditions of the nose. Many of the attacks of severe headaches
in children are of this nature, and the eyes and nostrils should be exam-
ined with great care. Sinkler refers to a case in a child of two years, and
Gowers states that a third of all the cases begin between the fifth and tenth
years of age. The direct influences inducing the attack are very varied.
Powerful emotions of all sorts are the most potent. Mental or bodily fatigue,
digestive disturbances, or the eating of some particular article of food may be
followed by the headache. The paroxysmal character is one of the most
striking features, and the attacks may recur on the same day every week,
every fortnight, or every month. Headaches of the migraine type may recur
for years in connection with chronic Bright's disease.
Symptoms. — Premonitory signs are present in many cases, and the patient
can tell when an attack is coming on. Eemarkable prodromata have been
described, particularly in connection with vision. Apparitions may appear —
visions of animals, such as mice, dogs, etc. Transient hemianopia or scotoma
may be present. In other instances there is spasmodic action of the pupil on
the affected side, which dilates and contracts alternately, the condition known
as liippus. Frequently the disturbance of vision is only a blurring, or there
are balls of light, or zigzag lines, or the so-called fortification spectra (teichop-
sia), which may be illuminated with gorgeous colors. Disturbances of the
other senses are rare. Numbness of the tongue and face and occasionally of
the hand may occur with tingling. More rarely there are cramps or spasms
in the muscles of the affected side. Transient aphasia has also been noted.
Some patients show marked psychical disturbance, either excitement or, more
commonly, mental confusion or great depression. Dizziness occurs in some
cases. The headache follows a short time after the prodromal symptoms have
appeared. It is cumulative and expansile in character, beginning as a localized
small spot, which is generally constant either on the temple or forehead or in
the eyeball. It is usually described as of a penetrating, sharp, boring charac-
ter. The pain gradually spreads and involves the entire side of the head,
sometimes the neck, and may pass into the arm. In some cases both sides
are afi^ected. ISTausea and vomiting are common symptoms. If the attack
comes on when the stomach is full, vomiting usually gives relief. 'Vasomotor
symptoms may be present. The face, for instance, may be pale, and there may
be a marked difference between the two sides. Subsequently the face and ear
on the affected side may become a burning red from the vaso-dilator influences.
The pulse may be slow. The temporal artery on the affected side may be firm
and hard, and in a condition of arterio-sclerosis — a fact which has been con-
firmed anatomically by Thoma. Few affections are more prostrating than
migraine, and during the paroxysm the patient may scarcely be able to raise
the head from the pillow. The slightest noise or light aggravates the condition.
The duration of the entire attack is variable. The severer forms usually
1068 DISEASES OF THE NERVOUS SYSTEM.
incapacitate the patient for at least three days. In other instances the entire
attack is over in a day. The disease recurs for years, and in cases with a
marked hereditary tendency may persist throughout life. In women the
attacks often cease after the climacteric, and in men after the age of fifty.
Two of the greatest sufferers I have known, who had recurring attacks every
few weeks from early boyhood, now have complete freedom.
The nature of the disease is unknown. Liveing's view, that it is a nerve
storm or form of periodic discharge from certain sensory centres, and is related
to epilepsy, has found much favor. According to this view, it is the sensory
equivalent of a true epileptic attack. Mollendorf, Latham, and others regard
it as a vaso-motor neurosis, and hold that the early symptoms are due to vaso-
constrictor and the later symptoms to vaso-dilator influences. The fact of the
development of arterio-sclerosis in the arteries of the afi^ected side is a point
of interest hearing upon this view.
Treatment. — The patient is fully aware of the causes which precipitate an
attack. Avoidance of excitement, regularity in the meals, and moderation in
diet are important rules. I have known cases greatly benefited by a strict
vegetable diet. The treatment should be directed toward the removal of the
conditions upon which the attacks depend. In children much may be done
by watchfulness and care on the part of the mother in regulating the bowels
and watching the diet of the child. Errors of refraction should be adjusted.
On no account should such children be allowed to compete in school for prizes.
A prolonged course of bromides sometimes proves successful. If anemia is
present, iron and arsenic should be given. When the arterial tension is in-
creased a course of nitroglycerin may be tried. Not too much, however, should
be expected of the preventive treatment of migraine. In a very large proportion
of the cases the headaches recur in spite of all we (including the refractionists)
can do, Herter advises, so soon as the patient has any intimation of the attack,
to wash out the stomach with water at 105°, and to give a brisk saline cathartic.
During the paroxysm the patient should be kept in bed and absolutely quiet.
If the patient feels faint and nauseated, a small cup of hot, strong coffee or 30
drops of chloroform give relief. Cannabis indica is. probably the most satis-
factory remedy. Seguin recommends a prolonged course of the drug. Anti-
pyrin, antifebrin, and phenacetin have been much used of late. When given
early, at the very outset of the paroxysm, they are sometimes effective. Small,
repeated doses are more satisfactory. Of other remedies, caffeine, in 5-grain
doses of the citrate, nux vomica, and ergot have been recommended. Elec-
tricity does not appear to be of much service. And lastly, in obstinate cases,
an ordinary tape seton may be inserted through the skin at the back of the
neck, to be worn for three months, a plan of treatment which has the strongest
possible recommendation from Mr. Whitehead, of Manchester.
VIII. NEURALGIA.
Definition. — A painful affection of the nerves, due either to functional
disturbance of their central or peripheral extremities or to neuritis in their
course.
Etiology. — Members of neuropathic families are most subject to the disease.
It affects women more than men. Children are rarely attacked. Of all causes^
GENERAL AND FUNCTIONAL DISEASES. 1069
debility is the most frequent. It is often the first indication of an enfeebled
nervous system. The various forms of anaemia are frequently associated with
neuralgia. It may be a prominent feature at the onset of certain acute dis-
eases, particularly typhoid fever. Malaria has been thought to be a potent
cause (0. W. Holmes' Boylston Essay), but it has not been shown that neural-
gia is more frequent in malarial districts, and the error has probably arisen
from regarding periodicity as a special manifestation of paludism. It occa-
sionally occurs in malarial cachexia. Exposure to cold is a cause in very
susceptible persons. Eeflex irritation, particularly from carious teeth, and
disease of the antrum and frontal sinuses, are common causes of neuralgia of
the fifth nerve. The disease occurs sometimes in rheumatism, gout, lead poi-
soning, and diabetes. Persistent neuralgia may be a feature of latent Blight's
disease.
Symptoms. — Before the onset of the pain there may be uneasy sensations,
sometimes tingling in the part which will be affected. The pain is localized
to a certain group or division of nerves, usually affecting one side. The pain
is not constant, but paroxysmal, and is described as stabbing, burning, or
darting in character. The skin may be exquisitely tender in the affected
region, particularly over certain points along the course of the nerve, the
so-called tender points. Movements, as a rule, are painful. Trophic and
vaso-motor changes may accompany the paroxysm; the skin may be cool, and
subsequently hot and burning; occasionally local oedema or erythema occurs.
More remarkable still are the changes in the hair, which may become blanched
(canities), or even fall out. Fortunately, such alterations are rare. Twitch-
ings of the muscles, or even spasms, may be present during the paroxysm.
After lasting a variable time — from a few minutes to many hours — the attack
subsides. Kecurrence may be at definite intervals — every day at the same hour,
or at intervals of two, three, or even seven days. Occasionally the paroxysms
develop only at the catamenia. This periodicity is quite as marked in non-
malarial as in malarial regions.
Clinical Vakieties, Depending on the Nerve Eoots Aeeected.
(1) Trigeminal Neuralgia; Tic Douloureux. — A distinction must be drawn
between the minor and major neuralgias of the fifth cranial nerve. The former
may merely be symptomatic of the involvement of one or another of its periph-
eral branches in some disease process — the pressure of a tumor, carious teeth,
or a neuritis due to the proximity of suppurative processes in the bony sinuses,
etc. There may be referred neuralgic pains in this area from morbid processes
within the cranium, or from visceral disease elsewhere. A painful neuralgia
may follow an attack of zoster in any division of the fifth nerve.
The typical tic douloureux, epileptiform neuralgia, or " neuralgia quinti
major/' as it has been called by Henry Head, whose article in Allbutt's System
should be consulted, is probably a primary affection of the nerve. The disease
starts in middle life, without obvious cause, as a simple neuralgia in one of
the trigeminal branches, and from a particular spot the pain radiates through
the course of one of the nerves. The pain is of sudden onset, violent and
paroxysmal in character. There are periods of remission, which at first may
extend over several months, and in which the paroxysms do not occur, but
1070 DISEASES OF THE NERVOUS SYSTEM.
these intervals of release shorten after each successive attack. The attacks
themselves are of ever increasing severity and longer duration. The paiu
finally invades the territory of adjoining nerves and ultimately, after years,
may extend over the entire trigeminal distribution. Though by sympathy there
may be pain outside of the fifth nerve area, particularly in the occipital region,
in true tic douloureux, the pain remains limited to the distribution of one
trigeminal nerve, and probably never becomes bilateral. In advanced cases
the paroxysms follow one another rapidly and without assignable cause, and in
the intervals the patient may never be quite free from pain. They are inaug-
urated by almost any form of external stimulus, by a draught of air, by move-
ment of the facial muscles or of the tongue in speaking, by touching the skin,
particularly over those points from which the pain seems to take its origin,
by the act of swallowing, especially when the pain involves the mucous mem-
brane field of distribution of the nerve. It is not a self-limited disease. In
some instances the neuralgia reaches such a frightful intensity that it renders
the patient's life insupportable. In former years suicide was not an uncom-
mon consequence.
Xo anatomical lesion that may be considered peculiar to the disease has
been described.
In the more severe cases medicinal forms of treatment are unavailing.
Surgical measures must be resorted to, and peripheral operations on the nerves
most affected often give complete, though only temporary, relief. Extirpation
of the Gasserian ganglion, as first proposed by Krause and Hartley, must be
contemplated. Complete restoration to health and permanent freedom from
pain seem always to follow its complete removal.
(3) Cervico-occipital neuralgia involves the posterior branches of the first
four cervical nerves, particularly the inferior occipital, at the emergence of
which there is a painful point about half-way between the mastoid process and
the first cervical vertebra. It may be caused by cold, and these nerves are
often affected in cervical caries. Surgical measures may be required if the pain
is severe. Krause has devised an operation for division and evulsion of the
affected nerves.
(3) Cervico-brachial neuralgia involves the sensory nerves of the brachial
plexus, particularly in the cubital division. When the circumflex nerve is in-
volved the pain is in the deltoid. The pain is most commonly about the
shoulder and down the course of the ulnar nerve. There is usually a marked
tender point upon this nerve at the elbow. This form rarely follows cold,
but more frequently results from rheumatic affections of the joints, and
trauma,
(4) Neuralgia of the phrenic nerve is rare. It is sometimes found in
pleurisy and in pericarditis. The pain is chiefly at the lower part of the
thorax on a line with the iusertion of the diaphragm, and here may be painful
points on deep pressure. Full inspiration is painful, and there is great sensi-
tiveness on coughing or in the performance of any movement by which the
diaphragm is suddenly depressed.
(5) Intercostal Neuralgia. — Xext to the tic douloureux this is the most
important form. It is most frequent in women and very common in hysteria.
Post-zoster neuralgias are common in this situation. The possibility of spinal
disease, of tumor, caries, or aneurism must always be borne in mind.
GENERAL AND FUNCTIONAL DISEASES. 1071
(6) Lumbar Neuralgia. — The affected nerves are the posterior fibres of the
lumbar plexus, particularly the ilio-scrotal branch. The pain is in the region
of the iliac crest, along the inguinal canal, in the spermatic cord, and in the
scrotum or labium majus. The affection known as irritable testis, probably a
neuralgia of this nerve, may be very severe and accompanied by syncopal
sensations.
(7) Coccydynia. — This is regarded as a neuralgia of the coccygeal plexus.
It is most common in women, and is aggravated by the sitting posture. It
is very intractable, and may necessitate the removal of the coccyx, an operation,
however, which is not always successful. Neuralgias of the nerves of the leg
have already been considered.
(8) Neuralgias of the Nerves of the Feet. — ^Many of these cases accompany
varying degrees of flat-foot. The condition is brought about by weakness or
fatigue of the muscles supporting the arches of the foot, which consequently
settle until the strain of the superimposed body-weight falls upon the liga-
mentous and aponeurotic attachments between the metatarsal and tarsal bones.
Eest, massage, exercises, and orthopaedic measures are indicated.
Painful Heel. — Both in women and men there may be about the heel
severe pains which interfere seriously with walking — the pododynia of S. D.
Gross. There may be little or no swelling, no discoloration, and no affection
of the joints.
Plantar Neuralgia. — This is often associated with a definite neuritis,
such as follows typhoid fever, and has been seen in an aggravated form in
caisson disease (Hughes). The pain may be limited to the tips of the toes
or to the ball of the great toe. Numbness, tingling, and hypersesthesia or
sweating may occur with it. Following the cold-bath treatment in typhoid
fever it is not uncommon for patients to complain of great sensitiveness in
the toes.
Metatarsalgia. — Thomas G-. Morton's "painful affection of the fourth
metatarso-phalangeal articulation " is a peculiar and very trying disorder, seen
most frequently in women, and usually in one foot. Morton regards it as due
to a pinching of the metatarsal nerve. The condition usually requires oper-
ation. The red, painful neuralgia — erythromelalgia — is described under the
vaso-motor and trophic disturbances.
(9) Visceral Neuralgias. — The more important of these have already been
referred to in connection with the cardiac and the gastric neuroses. They are
most frequent in women, and are constant accompaniments of neurasthenia
and hysteria. The pains are most common in the pelvic region, particularly
about the ovaries. Nephralgia is of great interest, for, as has already been
mentioned, the symptoms may closely simulate those of stone.
Treatment of Neuralgia. — In general, causes of reflex irritation should be
carefully removed. The neuralgia, as a rule, recurs unless the general health
improves ; so that tonic and hygienic measures of all sorts should be employed.
Often a change of air or surroundings will relieve a severe neuralgia. I have
known obstinate cases to be cured by a prolonged residence in the mountains,
with an out-of-door life and plenty of exercise. A strict vegetable diet will
sometimes relieve the neuralgia or headache of a gouty person. Of general
remedies, iron is often a specific in the cases associated with chlorosis and
anaemia. Arsenic, too, is very beneficial in these forms, and should be given
1072 DISEASES OF THE NERVOUS SYSTEM.
in ascending doses. The value of quinine has been much overrated. It prob-
ably has no more influence than any other bitter tonic, except in the rare
instances in which the neuralgia is definitely associated with malarial poison-
ing. Strychnine, cod-liver oil, and phosphorus are also advantageous. Of
remedies for the pain, antipyrin, antifebrin, and phenacetin should first be
tried, for they are sometimes of service. Morphia should be given with great
caution, and only after other remedies have been tried in vain. On no con-
sideration should the patient be allowed to use the. hypodermic syringe. Gel-
semium is highly recommended. Of nerve stimulants, valerian and ether,
which often act well together, may be given. Alcohol is a valuable though
dangerous remedy, and should not be ordered for women. In the minor form
of trigeminal neuralgia nitroglycerin in large doses may be tried. Dana has
seen good results follow rest with large doses of strychnia given hypodermi-
cally. Aconitia in doses of from one two-hundredth to one one-hundred-and-
fiftieth of a grain may be tried. In gouty and rheumatic subjects cannabis
indica and cimicifuga are recommended with the lithium salts.
Of local applications, the thermo-cautery is invaluable, particularly in
zona and the more chronic forms of neuralgia. Acupuncture may be used.
Chloroform liniment, camphor and chloral, menthol, the oleates of morphia,
atropia, and belladonna used with lanolin may be tried. Freezing over the
tender point with ether spray is sometimes successful. The continuous cur-
rent may be used. The sponges should be warm, and the positive pole should
be placed near the seat of the pain. The strength of the current should be
such as to cause a slight tingling or burning, but not pain.
Many of the more intractable forms of neuralgia can be relieved only by
surgical treatment.
IX. PROFESSIONAL. SPASMS; OCCUPATION
NEUROSES.
The continuous and excessive use of the muscles in performing a certain
movement may be followed by an irregular, involuntary spasm or cramp, which
may completely check the performance of the action. The condition is found
most frequently in writers, hence the term writer's cramp or scrivener's palsy;
but it is also common in piano and violin players and in telegraph operators.
The spasms occur in many other persons, such as milkmaids, weavers, and
cigarette-rollers.
The most common form is writer's cramp, which is much more frequent
in men than in women. Of 75 cases of impaired writing power reported by
Poore, all of the instances of undoubted writer's cramp were in men. Morris
J. Lewis states that in the United States, in the telegrapher's cramp, women,
who are employed a great deal in telegraphy, are much less frequently affected
(only 4 out of 43 cases). Persons of a nervous temperament are more liable
to the disease. Occasionally it follows slight injury,
Gowers states that in a majority of the cases a faulty method of writing
has been employed, using either the little finger or the wrist as the fixed point.
Persons who write with the middle of the forearm or the elbow as the fixed
point are rarely affected.
ISTo anatomical changes have been found. The most reasonable explanation
GENERAL AND FUNCTIONAL DLSEASES. 1073
of the disease is that it results from a deranged action of the nerve-centres
presiding over the muscular movements involved in the act of writing, a con-
dition which has been termed irritable weakness. " The education of centres
which may be widely separated from each other for the performance of any
delicate movement is mainly accomplished by lessening the lines of resistance
between them, so that the movement, which was at first produced by a con-
siderable mental effort, is at last executed almost unconsciously. If, there-
fore, through prolonged excitation, this lessened resistance be carried too far,
there is an increase and irregular discharge of nerve energy, which gives rise
to spasm and disordered movement. According to this view, the muscular
weakness is explained by an impairment of nutrition accompanying that of
function, and the diminished f aradic excitability by the nutritional disturbance
descending the motor nerves " (Gay).
Symptoms. — These may be described under five heads (Lewis).
(a) Cramp or Spasm. — This is often an early symptom and most com-
monly affects the forefinger and thumb; or there may be a combined move-
ment of flexion and adduction of the thumb, so that the pen may be twisted
from the grasp and throvru to some distance. Weir Mitchell has described
a lock-spasm, in which the fingers become so firmly contracted upon the pen
that it can not be removed.
(6) Paresis and Paralysis. — This may occur with the spasm or alone.
The patient feels a sense of weakness and debility in the muscles of the hand
and arm and holds the pen feebly. Yet in these circumstances the grasp of
the hand may be strong and there may be no paralysis for ordinary acts.
(c) Tremor. — This is most commonly seen in the forefinger and may be
a premonitory symptom of atrophy. It is not an important symptom, and is
rarely sufficient to produce disability.
(d) Pain. — Abnormal sensations, particularly a tired feeling in the mus-
cles, are very constantly present. Actual pain is rare, but there may be irregu-
lar shooting pains in the arm. Numbness or soreness may exist. If, as some-
times happens, a subacute neuritis develops, there may be pain over the nerves
and numbness or tingling in the fingers.
(e) Vaso-motor Disturbances. — These may occur in severe cases. There
may be hypersesthesia. Occasionally the skin becomes glossy, or there is a
condition of local asphyxia resembling chilblains. In attempting to write, the
hand and arm may become fiushed and hot and the veins increased in size.
Early in the disease the electrical reactions are normal, but in advanced cases
there may be diminution of faradic and sometimes increase in the galvanic
irritability.
Diagnosis. — A well-marked case of writer's cramp or palsy could scarcely
be mistaken for any other affection. Care must be taken to exclude the exist-
ence of any cerebro-spinal disease, such as progressive muscular atrophy or
hemiplegia. The physician is sometimes consulted by nervous persons who
fancy they are becoming subject to the disease and complain of stiffness or
weakness without displaying any characteristic features.
Prognosis. — The course of the disease is usually chronic. If taken in
time and if the hand is allowed perfect rest, the condition may improve rapidly,
but too often there is a strong tendency to recurrence. The patient may learn
to write with the left hand, but this also may after a time be attacked.
1074 DISEASES OF THE NERVOUS SYSTEM.
Treatment. — Various prophylactic measures have been advised. As men-
tioned, it is important that a proper method of writing be adopted. Gowers
suggests that if all persons wrote from the shoulder ^vriter's cramp would
practically not occur. Various devices have been invented for relieving the
fatigue, but none of them are very satisfactory. The use of the type-writer
has diminished very much the frequency of scrivener's palsy. Rest is essential.
'No measures are of value without this. Massage and manipulation, when
combined with systematic gymnastics, give the best results. Poore recommends
the galvanic current applied to the muscles, which are at the same time rhyth-
mically exercised. In very obstinate cases the condition remains incurable.
I saw a few years ago a distinguished gynaecologist who had had writer's
cramp twenty years before, and who had tried all sorts of treatment, including
Wolff's method, without any avail. He still has it in aggravated form,
but he can do all the finer manipulations of operative work without any
difficulty.
The nutrition of the patients is apt to be much impaired, and cod-liver oil,
strychnia, and other tonics will be found advantageous. Local applications are
of little benefit. Tenotomy and nerve-stretching have been abandoned.
X. TETANY.
Definition. — An affection characterized by peculiar bilateral tonic spasms
of the extremities, either paroxysmal or continued.
Etiology. — The disease occurs under very different conditions, of which
the following classification of Frankl-Hochwart is the most satisfactory:
(a) Tetany of Adults. — (1) Epidemic tetany, also known as rheumatic
tetany, idiopathic workman's tetany or shoemaker's cramp. In certain parts of
the Continent of Europe the disease has prevailed widely, particularly in the
winter season. Von Jacksch, who has described an epidemic form occurring
in young men of the working classes, sometimes with slight fever, regards the
disease as infectious. This form is acute, lasting only two or three weeks, and
rarely proving fatal.
(2) Tetany of gastric and intestinal disorders, as dyspepsia, gastrectasis,
diarrhoea, and helminthiasis. The form associated with dilatation of the stom-
ach is rare, not more than 30 cases having been reported.
(3) Tetany of the acute infectious diseases (typhoid, cholera, influenza,
measles, scarlatina, etc.). In some typhoid epidemics many cases have occurred.
(4) Tetany following poisoning from chloroform, morphia, ergot, lead,
alcohol, and uraemia. Isolated examples of each have been reported.
( 5 ) Tetany may also develop during pregnancy or recur in successive preg-
nancies. From its occurrence in nursing women. Trousseau called it " nurse's
contracture."
(6) Tetany following removal of the thyroid gland is probably due to a
removal of the parathyroid bodies at the same time. Before these bodies were
known to have any physiological function it was supposed that the removal of
the thyroid alone might produce tetany, and many post-operative cases of this
sort, like those from Billroth's clinic, have been recorded. James Stewart has
reported an instance in which with the tetany there were symptoms of myxoe-
dema and no trace of the thyroid gland.
GENERAL AND FUNCTIONAL DISEASES. 1075
(7) Tetany may complicate other nervous disorders, as Basedow's disease,
cerebral tumor, cysts of the cerebellum, and syringomyelia.
(6) Tetany in Children. — Tetany bears a definite relation to gastro-
intestinal disorders, acute infections, and rickets in childhood.
In the United States true tetany is an extremely rare disease. Griffith, in
1895, collected 77 cases, among which cases of carpo-pedal spasm are included.
During the past ten years an additional 70 cases have appeared in American
literature. In my wards at the Johns Hopkins Hospital there were 8 cases
of undoubted tetany; 4 complicating dilatation of the stomach, 2 hyperacidity
without dilatation, 1 case with chronic diarrhoea, and 1 occurring in repeated
pregnancies and lactation.
Morbid Anatomy. — The nature of the disease is unknown. E. Peters found
in 8 post-mortems an interstitial neuritis of the extradural connective tissue,
affecting both motor and sensory nerves. Since the work of Gley, Vassale and
Generali, and others, it has been well established that the tetany following
extirpation of the thyroid is due not to the loss of the thyroid function, but to
the coincident removal of the parathyroid glands. Differences in the behavior
of carnivorous and herbivorous animals in this respect are due to the fact that
while in the carnivora the glands are attached to the thyroid, in the herbivora
two of them lie at a distant point. The function of the parathyroid seems to
consist in the neutralization of a poison produced in the course of metabolism.
When the parathyroids are removed this free poison acts upon the central
nervous system and produces tetany. Spontaneous tetany is apparently the
result of the production of so much of this unknown poison that the nor-
mal parathyroids are insufficient to neutralize it. In a case of tetany follow-
ing gastric dilatation in an old man who died in my service at the Johns
Hopkins Hospital, the parathyroid cells were found by MacCallum to be
actively proliferating. Up to the present time there is no definite proof that
any other diseases are dependent upon lesions of the parathyroids.
Symptoms. — In cases associated with general debility or in children with
rickets the spasm is limited to the hands and feet. The fingers are bent at the
metaearpo-phalangeal joint, extended at the terminal joints, pressed close to-
gether, and the thumb is contracted in the. palm of the hand. The wrist is
flexed, the elbows are bent, and the arms are folded over the chest. In the
lower limbs the feet are extended and the toes adducted. The muscles of the
face and neck are less commonly involved, but in severe cases there may be
trismus, and the angles of the mouth are drawn out. The skin of the hands
and feet is sometimes tense and oedematous. The spasms are usually parox-
ysmal and last for a variable time. In children the attack may pass off in a
few hours. In some of the more severe chronic cases in adults the stiffness and
contracture may continue or even increase for many days, and the attack may
last as long as two weeks. In the acute cases the temperature may be elevated
and the pulse quickened. In the severe paroxysms there may be involvement
of the muscles of the back and of the thorax, inducing dyspnoea and cyanosis.
Certain additional features, valuable in diagnosis, are present.
Trousseau's symptom : " So long as the attack is not over, the paroxysms
may be reproduced at will. This is effected by simply compressing the affected
parts, either in the direction of their principal nerve trunks or over their
blood-vessels, so as to impede the venous or arterial circulation."
1076 DISEASES OF THE NERVOUS SYSTEM.
Chvostek's symptom is shown in the remarkable increase in the mechanical
excitability of the motor nerves, A slight tap, for example, in the course of
the facial nerve will throw the muscles to which it is distributed into active
contraction. Erb has shown that the electrical irritability of the motor nerves,
especially to the galvanic current, is also greatly increased, and Hofmann has
demonstrated the heightened excitability of the sensory nerves, the slightest
pressure on which may cause pargesthesia in the region of distribution.
Diagnosis. — The disease is readily recognized. It is a mistake to call
instances of carpo-pedal spasm of children true tetany. It is common to find
in rickety children or in cases of severe gastro-intestinal catarrh a transient
spasm of the fingers or even of the arms. By many authors these are consid-
ered cases of mild tetany, and there are all grades in rickety children between
the simple carpo-pedal spasm and the condition in which the four extremities
are involved ; but it is well, I think, to limit the term tetany to the more severe
affection.
With true tetanus the disease is scarcely ever confounded, as the commence-
ment of the spasm in the extremities, the attitude of the hands, and the etio-
logical factors are very different. Hysterical contractures are usually unilateral.
Treatment. — In the case of children the condition with which the tetany
is associated should be treated. Baths and cold sponging are recommended
and often relieve the spasm as promptly as in child-crowing. Bromide of
potassium may be tried. In severe cases chloroform inhalations may be given.
Massage, electricity, and the spinal ice-bag have also been used with success.
Cases, however, may resist all treatment, and the spasms recur for many years.
The thyroid extract should be tried. Gottstein reports relief in a case of long
standing, and Bramwell reports one case of operative tetany and one of the
idiopathic form successfully treated in this way.
In gastric tetany, especially when due to dilatation of the stomach, the
mortality is high, and recovery without operative interference is rare: of 27
cases collected by Eiegel, 16 terminated fatally. Cunningham collected 8 cases
treated surgically, with a mortality of 37.5 per cent, as compared with 70 per
cent treated by medical means. Eegular, systematic lavage with large quan-
tities of saline or mildly antiseptic solutions is sometimes beneficial.
XI. HYSTERIA.
Definition. — A state in which ideas control the body and produce morbid
changes in its functions (Mobius).
Etiology. — The affection is more common in women, and usually appears
first about the time of puberty, but the manifestations may continue until the
menopause, or even until old age. Men, however, are by no means exempt,
and of late years hysteria in the male has attracted much attention. It occurs
in all races, but is much more prevalent, particularly in its severer forms, in
members of the Latin race. In the United States the milder grades are com-
mon, but the graver forms are rare in comparison with the frequency with
which they are seen in France.
Children under twelve years of age are not very often affected, but the
disease may be well marked as early as the fifth or sixth year. One of the
saddest chapters in the history of human deception, that of the Salem witches,
GENERAL AND FUNCTIONAL DISEASES. 1077
might be headed hysteria in children^ since tlie tragedy resulted directly from
the hysterical pranks of girls under twelve years of age.
Of predisposing causes, two are important — heredity and education. The
former acts by endowing the child with a mobile, abnormally sensitive nervous
organization. We see cases most frequently in families with marked neuro-
pathic tendencies, the members of which have suffered from neuroses of vari-
ous sorts. Education at home too often fails to inculcate habits of self-control.
A child grows to girlhood with an entirely erroneous idea of her relations to
others, and accustomed to have every whim gratified and abundant sympathy
lavished on every woe, however trifling, she reaches womanhood with a moral
organization unfitted to withstand the cares and worries of every-day life. At
school, between the ages of twelve and fifteen, the most important period in
her life, when the vital energies are absorbed in the rapid development of the
body, she is often cramming for examinations and cooped in close school-rooms
for six or eight hours daily. The result too frequently is an active, bright mind
in an enfeebled body, ill adapted to subserve the functions for which it was
framed, easily disordered, and prone to react abnormally to the ordinary stimuli
of life. Among the more direct influences are emotions of various kinds,
fright occasionally, more frequently love affairs, grief, and domestic worries.
Physical causes less often bring on hysterical outbreaks, but they may follow
directly upon an injury or develop during the convalescence from an acute
illness or be associated with disease of the generative organs. The name
hysteria indicates how important was believed to be the part played by the
uterus in the causation of the disease. Opinions differ a good deal on this
question, but undoubtedly in many cases there are ovarian and uterine disorders
the rectification of which sometimes cures the disease. Sexual excess, particu-
larly masturbation, is an important factor, both in girls and boys.
Symptoms. — A useful division is into the convulsive and non-convulsive
varieties.
Convulsive Hysteria.
(a) MiNOE Forms. — The attack most commonly follows emotional disturb-
ance. It may set in suddenly or be preceded by symptoms, called by the laity
" hysterical,^' such as laughing and crying alternately, or a sensation of con-
striction in the neck, or of a ball rising in the throat — the globus hystericus.
Sometimes, preceding the convulsive movements, there may be painful sensa-
tions arising from the pelvic, abdominal, or thoracic regions. From the de-
scription these sensations resemble auras. They become more intense with the
rising sensation of choking in the neck and difficulty in getting breath, and the
patient falls into a more or less violent convulsion. It will be noticed that
the fall is not sudden, as in epilepsy, but the subject goes down, as a rule,
easily, often picking a soft spot, like a sofa or an easy-chair, and in the move-
ments apparently exercises care to do herself no injury. Yet at the same time
she appears to be quite unconscious. The movements are clonic and disorderly,
consisting of to-and-fro motions of the trunk or pelvic muscles, while the head
and arms are thrown about in an irregular manner. The paroxysm after a
few minutes slowly subsides, then the patient becomes emotional, and gradually
regains consciousness. When questioned the patient may confess to having
some knowledge of the events which have taken place, but, as a rule, has no
1078 DISEASES OF THE NERVOUS SYSTEM.
accurate recollection. During the attack the abdomen may be much distended
with flatus, and subsequently a large amount of clear urine may be passed.
These attacks vary greatly in character. There may be scarcely any move-
ments of the limbs, but after a nerve storm the patient sinks into a torpid,
semi-unconsciousness condition, from which she is roused with great difficulty.
In some cases from this state the patient passes into a condition of catalepsy.
(&) Major Forms; Hystero-epilepsy. — This condition has been espe-
cially studied by Charcot and his pupils. Typical instances passing through
the various phases are very rare in the United States and in England. The
attack is initiated by certain prodromata, chiefly minor hysterical manifesta-
tions, either foolish or unseemly behavior, excitement, sometimes dyspeptic
symptoms with tympanites, or frequent micturition. Areas of hyperesthesia
may at this time be marked, the so-called hysterogenic spots so elaborately de-
scribed by Eichet. These are usually symmetrical and situated over the upper
dorsal vertebra, and in front in a series of symmetrically placed spots on the
chest and abdomen, the most marked being those in the inguinal regions over
the ovaries. Painful sensations or a feeling of oppression and a globus rising
in the throat may be complained of prior to the onset of the convulsion, which,
according to French writers, has four distinct stages : ( 1 ) Epileptoid condition,
which closely simulates a true epileptic attack with tonic spasm (often leading
to opisthotonus), grinding of the teeth, congestion of the face, followed by
clonic convulsions, gradual relaxation, and coma. This attack lasts rather
longer than a true epileptic attack. (3) Succeeding this is the period which
Charcot has termed downism, in which there is an emotional display and a
remarkable series of contortions or of cataleptic poses. (3) Then in typical
cases there is a stage in which tne patient assumes certain attitudes expressive
of the various passions — ecstasy, fear, beatitude, or erotism. (4) Finally con-
sciousness returns and the patient enters upon a stage in which she may display
very varied symptoms, chiefly manifestations of a delirium with the most
extraordinary hallucinations. Visions are seen, voices heard, and conversations
held with imaginary persons. In this stage patients will relate with the ut-
most solemnity imaginary events, and make extraordinar}^ and serious charges
against individuals. This sometimes gives a grave aspect to these seizures, for
not only will the patient at this stage make and believe the statements, but
when recovery is complete the hallucination sometimes persists. I have rarely
seen in the United States attacks having this orderly sequence. Much more
commonly the convulsions succeed each other at intervals for several days in
succession. Here we have a striking difference between hystero-epilepsy and
true epilepsy. In the latter the status epilepticus, if persistent, is always
serious, associated with fever, and frequently fatal, while in hystero-epilepsy
attacks may recur for days without special danger to life. After an attack
of hystero-epilepsy the patient may sink into a state of trance or lethargy, in
which she may remain for days.
Non-convulsive Forms.
So complex and varied is the clinical picture of hysteria that various mani-
festations are best considered according to the systems which are involved.
Disorders of Motion. — (a) Paralyses. — These may be hemiplegic, para-
plegic, or monoplegic. Hysterical diplegia is extremely rare. The (paralysis
GENERAL AND FUNCTIONAL DISEASES. 1079
either sets in abruptly or gradually, and may take weeks to attain its full
development. There is no type or form of organic paralysis which may not
he simulated in hysteria. According to Weir Mitchell, the hemiplegias are
four times more frequent on the left than on the right side. The face is not
affected; the neck may be involved, but the leg suffers most. Sensation is
either lessened or lost on the affected side. The hysterical paraplegia is more
common than hemiplegia. The loss of power is not absolute; the legs can
usually be moved, but do not support the patient. The reflexes may be in-
creased, though the knee-jerk is often normal. A spurious ankle clonus may
sometimes be present. The feet are usually extended and turned inward in the
equino-varus position. The muscles do not waste and the electrical reactions
are normal. Other manifestations, such as paralysis of the bladder or aphonia,
are usually associated with the hysterical paraplegia. Hysterical monoplegias
may be facial, crural, or brachial. A condition of ataxia sometimes occurs
with paresis. The incoordination may be a marked feature, and there are
usually sensory manifestations.
(6) Contractures and Spasms. — There is an extraordinary variety of spas-
modic affections in hysteria, of which the most common are the following:
The hysterical contractures may attack almost any group of voluntary muscles
and be of the hemiplegie, paraplegic, or monoplegic type. They may come
on suddenly or slowly, persist for months or years, and disappear rapidly. The
contracture is most commonly seen in the arm, which is flexed at the elbow
and wrist, while the fingers tightly grasp the thumb in the palm of the hand;
more rarely the terminal phalanges are hyperextended as in athetosis. It may
occur in one or in both legs, more commonly in one. The ankle clonus
is present; the foot is inverted and the toes are strongly flexed. These cases
may be mistaken for lateral sclerosis and the difficulty in diagnosis may really
be very great. The spastic gait is very typical, and with the exaggerated knee-
jerk and ankle clonus the picture may be characteristic. In 1879 I frequently
showed such a case at the Montreal General Hospital as a typical example of
lateral sclerosis. The condition persisted for more than eighteen months and
then disappeared completely. Other forms of contracture may be in the
muscles of the hip, shoulder, or neck ; more rarely in those of the jaws — hys-
terical trismus — or in the tongue. Eemarkable indeed are the local contrac-
tures in the diaphragm and abdominal muscles, producing a phantom tumor,
in which just below and in the neighborhood of the umbilicus is a flrm, appar-
ently solid growth. According to Gowers, this is produced by relaxation of
the recti and a spasmodic contraction of the diaphragm, together with infla-
tion of the intestines with gas and an arching forward of the vertebral column.
They are apt to occur in middle-aged women about the menopause, and are
frequently associated with the symptoms of spurious pregnancy — pseudo-cyesis.
The resemblance to a tumor may be striking, and I have known skilful diag-
nosticians to be deceived. The only safeguard is to be found in complete
anaesthesia, when the tumor entirely disappears. Some years ago I went by
chance into the operating-room of a hospital and found a patient on the table
under chloroform and the surgeon prepared to perform ovariotomy. The
tumor, however, had completely disappeared with full anaesthesia. Mitchell
has reported an instance of a phantom tumor in the left pectoral region just
above the breast, which was tender, hard, and dense.
1080 DISEASES OF THE NERVOUS SYSTEM.
Clonic spasms are more common in hysteria in this country than contrac-
tures. The following are the important forms: Rhythmic hysterical spasm.
This, unfortunately, is sometimes known as rhythmic chorea or hysterical
chorea. The movements may be of the arm, either flexion and extension, or,
more rarely, pronation and supination. Clonic contractions of the sterno-
eleido-mastoid or of the muscles of the jaws or of the rotatory muscles of the
head may produce rhythmic movements of these parts. The spasm may be in
one or both psoas muscles, lifting the leg in a rh}i:hmic manner eight or ten
times in a minute. In jDther instances the muscles of the trunk are atfected,
and every few moments there is a bowing movement — salaam convulsions — or
the muscles of the back may contract, causing strong arching of the vertebral
column and retraction of the head. These movements may often alternate, as
in a case in my wards, in which the patient on fine days had regular salaam
convulsions, while on wet days the rhythmic spasm was in the muscles of the
back and neck. Mitchell has described a rotatory spasm in which the patient
rotated involuntarily, usually to the left. More unusual cases are those in
which the contractions closely simulate paramyoclonus multiplex. Hysterical
athetosis is a rare form of spasm. Tremor may be a purely hysterical mani-
festation, occurring either alone or with paralysis and contracture. It most
commonly involves the hands and arms; more rarely the head and legs. The
movements are small and quick. In the ty^e described by Eendu the tremor
may or may not persist during repose, but it is increased or provoked by voli-
tional movements. Volitional or intentional tremor may exist, simulating
closely the movements of insular sclerosis. Buzzard states that many instances
of this disease in young girls are mistaken for hysteria.
DisoEDEES OF Sexsation. — AncEsthesia is most common, and usually con-
fined to one half of the body. It may not be noticed by the patient. Usually
it is accurately limited by the middle line and involves the mucous surfaces and
deeper parts. The conjunctiva, however, is often spared. There may be hemi-
anopia. This sjmiptom may come on slowly or follow a convulsive attack.
Sometimes the various sensations are dissociated and the anesthesia may be
only to pain and to touch. The skin of the affected side is usually pale and
cool, and a pin-prick may not be followed by blood. With the loss of feeling
there may be loss of muscular power. Curious trophic changes may be present,
as in an interesting case of Weir Mitchell's, in which there was unilateral
swelling of the hemiplegic side.
A phenomenon to which much attention has been paid is that of transfer-
ence. By metallotherapy, the application of certain metals, the ansesthesia
or analgesia can be transferred to the other side of the body. It has been
shown, however, that this phenomenon may be caused b}^ the electro-magnet
and by wood and various other agents, and is probably entirely a mental effect.
The subject has no practical importance, but it remains an interesting and
instructive chapter in Gallic medical history.
Hypercesthesia. — Increased sensitiveness and pains occur in various parts
of the body. One of the most frequent complaints is of pain in the head,
usually over the sagittal suture, less frequently in the occiput. This is de-
scribed as agonizing, and is compared to the driving of a nail into the part;
hence the name clavus hystericus. ISTeuralgias are common. Hypergesthetic
areas, the hysterogenic points, exist on the skin of the thorax and abdomen,
GENERAL AND FUNCTIONAL DISEASES. 1081
pressure upon which may cause minor manifestations or even a convulsive
attack. Increased sensitiveness exists in the ovarian region, but is not pecul-
iar to hysteria. Pain in the back is an almost constant complaint of hysterical
patients. The sensitiveness may be limited to certain spinous processes, or it
may be diffuse. In hysterical women the pains in the abdomen may simulate
those of gastralgia and of gastric ulcer, or the condition may be almost identical
with that of peritonitis ; more rarely the abdominal pains closely resemble those
of appendix disease.
Special Senses. — Disturbances of taste and smell are not uncommon and
may cause a good deal of distress. Of ocular symptoms, retinal hypergesthesia
is the most common, and the patients always prefer to be in a darkened roon;.
Eetraction of the field of vision is common and usually follows a convulsive
seizure. It may persist for years. The color perception may be normal even
with complete anaesthesia, and in America the achromatopsia does not seem
to be nearly so common an hysterical manifestation as in Europe. Hysterical
deafness may be complete and may alternate or come on at the same time with
hysterical blindness. Hysterical amaurosis may occur in children. One must
carefully distinguish between functional loss of power and simulation.
Visceral Manifestations. — Respiratory Apparatus. — Of disturbances in
the respiratory rhythm, the most frequent, perhaps, is an exaggeration of the
deeper breath, which is taken normally every fifth or sixth inspiration, or
there may be a " catching " breathing, such as is seen when cold water is
poured over a person. In hysterical dyspnoea there is no special distress and
the pulse is normal. In what is known as the syndrome of Briquet there is
shortness of breath, suppression of the voice, and paralysis of the diaphragm.
The anhelation is extreme. In rare instances there is bradypnoea. Among
laryngeal manifestations aphonia is frequent and may persist for months or
even years without other special symptoms of the disease. Spasm of the
muscles may occur with violent inspiratory efforts and great distress, and
may even lead to cyanosis. Hiccough, or sounds resembling it, may be present
for weeks or months at a time. Among the most remarkable of the respiratory
manifestations are the hysterical cries. These may mimic the sounds produced
by animals, such as barking, mewing, or grunting, and in France epidemics
of them have been repeatedly observed. Extraordinary cries may be produced,
either inspiratory or expiratory. I saw at Wagner's clinic at Leipsic a girl of
thirteen or fourteen, who had for many weeks given utterance to a remarkable
inspiratory cry somewhat like the whoop of whooping-cough, but so intense
that it was heard at a long distance. It was incessant, and the girl was worn
to a skeleton. Attacks of gaping, yawning, and sneezing may also occur.
The hysterical cough is a frequent symptom, particularly in young girls.
It may occur in paroxysms, but is often a dry, persistent, croaking cough,
extremely monotonous and unpleasant to hear. Sir Andrew Clark has called
attention to a loud, barking cough (cynoiex hehetica) occurring about the
time of puberty, chiefly in boys belonging to neurotic families. The attacks,
which last about a minute, recur frequently.
There is a peculiar form of haemoptysis which may be very deceptive and
lead to the diagnosis of pulmonary disorders. Wagner describes the sputum
as a pale-red fluid — ^not so bright in color as in ordinary haemoptysis; on set-
tling it presents a reddish-brown sediment. It contains particles of food, pave-
1082 DISEASES OF THE NERVOUS SYSTEM.
ment epithelium, red corpuscles, and micrococci, but no cylindrical or ciliated
epithelium. It probably comes from the mouth or pharynx.
Digestive System. — Disturbed or depraved appetite, dyspepsia, and gastric
pains are common in hysterical patients. The patient may have difficulty in
swallowing the food, apparently from spasm of the gullet. There are instances
in which the food seems to be expelled before it reaches the stomach. In other
cases there is incessant gagging. In the hysterical vomiting the food is regur-
gitated without much effort and without nausea. This feature may persist for
years without great disturbance of nutrition. The most striking and remark-
able digestive disturbance in hysteria is the anorexia nervosa described by Sir
William Gull. " To call it loss of appetite — anorexia — but feebly character-
izes the symptom. It is rather an annihilation of appetite, so complete that
it seems in some cases impossible ever to eat again. Out of it grows an
antagonism to food which results at last and in its worst forms in spasm on
the approach of food, and this in turn gives rise to some of those remarkable
cases of survival for long periods without food" (Mitchell). There are three
special features in anorexia nervosa : First, and most important, a psychical
state, usually depressant, occasionally excited and restless. It is not always
hysterical, and the condition should not rightly be considered here. Secondly,
stomach symptoms, loss of appetite, regurgitation, vomiting, and the whole
series of phenomena associated with nervous dyspepsia. Thirdly, emaciation,
which reaches a grade seen only in cancer and dysentery. The patient finally
takes to bed, and in extreme cases lies upon one side with the thighs and legs
flexed, and contractures may occur. Food is either not taken at all or only
upon urgent compulsion. The skin becomes wasted, dry, and covered with
bran-like scales. No food may be taken for several weeks at a time, and
attempts to feed may be followed by severe spasms. Although the condition
looks so alarming, these cases, when removed from their home surroundings
and treated by Weir Mitchell's method, sometimes recover in a remarkable
way. It may take many months before any improvement is noted. Death,
however, may follow with extreme emaciation. In a fatal case under my care
the girl weighed only 49 pounds. No lesions were found post mortem.
Hysterical tympanites is a common feature, caused usually by tonic con-
traction of the diaphragm and retraction of the other abdominal muscles. It
may be associated with the condition of peristaltic unrest (Kussmaul). Fre-
quent discharges of faeces may be due to disturbance in either the small or
large bowel. An obstinate form of diarrhoea is found in some hysterical
patients, which proves very intractable and is associated especially with the
taking of food. It seems an aggravated form of the looseness of bowels to
which so many nervous people are subject on emotion or of the tendency which
some have to diarrhoea immediately after eating. An entirely different form
is that produced by what Mitchell calls the irritable rectum, in which scybala
are passed frequently during the day, sometimes with great violence. Con-
stipation is more frequent, however, and may be due to a loss of power in the
muscles of the bowel, or in the abdominal muscles. In extreme cases the
bowels may not be moved for two or three weeks, leading to great accumula-
tion of faeces. Other disturbances are ano-spasm or intense pain in the rectum
apart from any fissure. Hysterical ileus and faecal vomiting are among the
most remarkable of hysterical phenomena. Following a shock there are con-
GENERAL AND FUNCTIONAL DISEASES. 1083
stipation, tympanites, vomiting, sometimes lia3matemesis. The constipation
grows worse, everything taken by the mouth is rejected, the vomitus jjecomes
faecal in character, even scybala are brought up, and suppositories and enemata
are vomited. The symptoms may continue for weeks and then gradually sub-
side. Laparotomy — even thrice in one patient — has shown a perfectly normal-
looking condition of the bowels (Parkes Weber).
Cardio-vascular. — Rapid action of the heart on the slightest emotion, with
or without the subjective sensation of palpitation, is often a source of great
distress. A slow pulse is less frequent. Pains about the heart may simulate
angina. Flushes in various parts are among the most common symptoms.
Sweating may occur, or the sehorrhoea nigricans, causing a darkening of the
skin of the eyelids.
Among the more remarkable vaso-motor phenomena are the so-called stig-
mata or ha3morrhages in the skin, such as were present in the celebrated case
of Louise Lateau. In many cases these are undoubtedly fraudulent, but if,
as appears credible, such bleeding may exist in the hypnotic trance, there seems
no reason to doubt its occurrence in the trance of prolonged religious ecstasy.
Joint Affections. — To Sir Benjamin Brodie and Sir James Paget we
owe the recognition of these extraordinary manifestations of hysteria. Per-
haps no single afEection has brought more discredit upon the profession, for
the cases are very refractory, and finally fall into the hands of a charlatan or
faith-healer, under whose touch the disease may disappear at once. Usually
it affects the knee or the hip, and may follow a trifling injury. The joint is
usually fixed, sensitive, and swollen. The surface may be cool, but sometimes
the local temperature is increased. To the touch it is very sensitive and
movement causes great pain. In protracted cases the muscles about the joint
are somewhat wasted, and in consequence it looks larger. The pains are often
nocturnal, at which time the local temperature may be much increased. While,
as a rule, neuromimetic joints yield to proper management, there are inter-
esting instances in the literature in which organic change has succeeded the
functional disturbance. In the remarkable case reported in Weir Mitchell's
lectures, the hysterical features were pronounced, and, on account of the chron-
icity, the disease of the knee-joint was considered organic by such an authority
as Billroth. Sands found the joint surfaces normal, and the thickening to be
due to inflammatory products outside the capsule.
Intermittent hydrarthrosis may be a manifestation of hysteria, occurring
in the knee or other joints, sometimes with transient paresis.
Mental Symptoms. — Janet makes suggestion the keystone of the mental
condition in hysteria, the test, indeed, of its existence; and in his recent
Harvard Lectures On Hysteria he states that suggestion " presents itself
experimentally or accidentally only with hystericals, and inversely all hys-
tericals present this same phenomenon in a higher or lower degree." Another
striking peculiarity is the perversion of the moral nature. Not the slightest
dependence can be placed upon the statements of hysterical patients. This
appears to result partly, but not wholly, from a morbid craving for sympathy.
Hysterical patients may become insane and display persistent hallucina-
tions and delirium, alternating perhaps with emotional outbursts of an aggra-
vated character. For weeks or months they may be confined to bed, entirely
oblivious to their surroundings, with a delirium which may simulate that of
1084 DISEASES OF THE NERVOUS SYSTEM.
delirium tremens, particularly in being associated with loathsome and un-
pleasant animals. The nutrition may be maintained, but in these cases there
is always a very heaxj, foul breath. With seclusion and care recovery usually
takes place within three or four months. At the onset of these attacks and
during convalescence the patients must be incessantly watched, as a suicidal
tendency is by no means uncommon. I have been accustomed to speak of this
condition as the status hystericus.
Of hysterical manifestations in the higher centres that of trance is the
most remarkable. This may develop spontaneously without any convulsive
seizure, but more frequently, in America at least, it follows hysteroid attacks.
Catalepsy may be present, a condition in which the limbs are plastic and
remain in any position in which they are placed.
The Metabolism in Htsteeia. — The studies of Gilles de la Tourette and
Cathelineau, under Charcot's direction, have shown that in the ordinary forms
of hysteria the urine does not show quantitative or qualitative changes, but
in the severer types, characterized by convulsions, etc., there are important
modifications : reduction in the urates and phosphates ; the ratio of the earthy
to the alkaline phosphates, normally 1 : 3, is 1 : 2, or even 1 : 1. The urine is
also reduced in amount. They think that these changes might sometimes serve
to differentiate convulsive hysteria from epilepsy, in which there is always an
increase in the solid constituents after a seizure.
Hysteeical Fever. — In hysteria the temperature, as a rule, is normal.
The cases with fever may be grouped as follows: (a) Instances in which the
fever is the sole manifestation. These are rare, but I have seen at least two
cases in which the chronic course, the retention of the nutrition, and the
entirely negative condition of the organs left no other diagnosis possible. In
a case which I had under observation the patient had for four or five years an
afternoon rise of temperature, reaching usually to 103° or 103°. She was well
nourished and presented no pronounced hysterical symptoms, beyond a form
of interrupted sighing respiration so often seen in hysteria. There was a
marked neurotic history on one side of the family.
(&) Cases of hysterical fever with spurious local manifestations. These
are very troublesome and deceptive cases. The patient may be suddenly taken
ill with pain in various regions and elevation of temperature. The case may
simulate meningitis. There may be pain in the head, vomiting, contracted
pupils, and retraction of the neck — symptoms which may persist for weeks —
and some anomalous manifestation during convalescence may alone indicate
to the physician that he has had to deal with a case of hysteria, and has not,
as he perhaps flattered himself, cured a case of meningitis. Mary Putnam
Jacobi, in an article on hysterical fever, mentions a case in the service of
Cornil which was admitted with dyspnoea, slight cyanosis, and a temperature
of 39° C. The condition proved to be hysterical. There is also an hysterical
pseudo-phthisis with pain in the chest, slight fever, and the expectoration of a
blood-stained mucus. The cases of hysterical peritonitis may also show fever.
(c) Hysterical Hyperpyrexia. — It is a suggestive fact that the cases of
paradoxical temperatures reported of late years, in which the thermometer has
registered 112° to 120° or more, have been in women. Fraud has been prac-
tised in some of these, but others have to be accepted, though their explanation
is impossible under our known laws.
GENERAL AND FUNCTIONAL DISEASES. 1085
Diagnosis. — Inquiry into the occurrence of previous manifestations and
the mental conditions may give important information. These questions, as
a rule, should not be asked the mother, who of all others is least likely to give
satisfactory information about the patient's condition. The occurrence of the
globus hystericus, of emotional attacks, of weeping and crying, are always
suggestive. The points of difference between the convulsive attacks and true
epilepsy were referred to in their description, and as a rule little difficulty is
experienced in distinguishing between the two conditions. The hysterical
paralyses are very variable and apt to be associated with anesthesia. The
contractures may at times be very deceptive, but the occurrence of areas of
anaesthesia, of retraction of the visual field, and the development of minor
hysterical manifestations, give valuable indications. The contractures disap-
pear under full anaesthesia. Special care must be taken not to confound the
spastic paraplegia of hysteria with lateral sclerosis.
The visceral manifestations are usually recognized without much difficulty.
The practitioner has constantly to bear in mind the strong tendency in hys-
terical patients to practise deception.
Treatment. — The prophylaxis in hysteria may be gathered from the re-
marks on the relation of education to the disease. The successful treatment
of hysteria demands qualities possessed by few physicians. The first element
is a due appreciation of the nature of the disease on the part of the physician
and friends. It is pitiable to think of the misery which has been inflicted on
these unhappy victims by the harsh and unjust treatment which has resulted
from false views of the nature of the trouble; on the other hand, worry and
ill-health, often the wrecking of mind, body, and estate, are entailed upon
the near relatives in the nursing of a protracted case of hysteria. The minor
manifestations, attacks of the vapors, the crying and weeping spells, are not
of much moment and rarely require treatment. The physical condition should
be carefully looked into and the mode of life regulated so as to insure system
and order in everything. A congenial occupation offers the best remedy for
many of these manifestations. Any functional disturbance should be attended
to and a course of tonics prescribed. Special attention should be paid to the
action of the bowels.
Valerian and asafcetida are often of service. For the pains in various
parts, particularly in the back, the thermo-cautery and static electricity will
be found invaluable. Morphia should be withheld. In the convulsive seizures,
particularly in the minor forms, it is often best, after settling the patient
comfortably, to leave her. When she comes to, and finds herself alone and
without sympathy, the attacks are less likely to be repeated. There is, as a
rule, no cure for the hysterical manifestations of women, otherwise in good
health, who are, as Mitchell says, " fat and ruddy, with sound organs and
good appetites, but ever complain of pains and aches, and ever liable on the
least emotional disturbance to exhibit a quaint variety of hysterical phe-
nomena."
To treat hysteria as a physical disorder is radically wrong. It is essentially
a mental and emotional anomaly, and the important element in the treatment
is moral control. At home, surrounded by loving relatives who misinterpret
entirely the symptoms and have no appreciation of the nature of the disease,
the severer forms of hysteria can rarely be cured. The necessary control is
1086 DISEASES OF THE NERVOUS SYSTEM.
impossible ; hence the special value of the method introduced by Weir Mitchell,
which is particularly applicable to the advanced cases which have become
chronic and bedridden. The treatment consists in isolation, rest, diet, massage,
and electricity. Separation from friends and sympathetic relatives must be
absolute, and can rarely, if ever, be obtained in the individual's home. An
essential element in the treatment is an intelligent nurse. No small share
of the success which has attended the author of this plan has been due to the
fact that he has persistently chosen as his allies bright, intelligent women. The
details of the plan are as follows: The patient is confined to bed and not
allowed to get up, nor, at first, in aggravated cases, to read, write, or even to
feed herself. Massage is used daily, at first for twenty minutes or half an
hour, subsequently for a longer period. It is essential as a substitute for exer-
cise. The induction current is applied to the various muscles and to the spine.
Its use, however, is not so essential as that of massage. The diet may at first
be entirely of milk, 4 ounces every two hours. It is better to give skimmed
milk, and it may be diluted with soda water or barley water and, if necessary,
peptonized. After a week or ten days the diet may be increased, the amount
of milk still being kept up. A chop may be given at midday, a cup of coffee
or cocoa with toast or bread and butter or a biscuit with the milk. The
patients usually fatten rapidly as the solid food is added, and with the gain
there is, as a rule, a diminution or cessation of the nervous symptoms. The
milk is the essential element in the diet, and is in itself amply sufficient.
The remarkable results obtained by this method are now universally recog-
nized. The plan is more applicable to the lean than to fat, fiabby hysterical
patients. Not only is it suitable for the more obstinate varieties with bodily
manifestations, but in the cases with mental symptoms the seclusion and sepa-
ration from relatives and friends are particularly advantageous. In the hys-
terical vomiting Debove's method of forced feeding may be used with benefit.
For the innumerable minor manifestations and for the simulations the indi-
cations for treatment are usually clear. All hysterical patients are subject
to suggestion, and hypnotism has been used extensively. In cases of contrac-
tion and of paralysis it is often of great help. Suggestion alone, without the
induction of the hypnotic state, may suffice to cure hysterical paralysis. In
careful hands it may be used, always remembering that hypnotism is a two-
edged sword with which many good men in the profession have been sore
smitten, and many patients more hurt than helped.
XII. NEURASTHENIA (Psychasthenia).
Definition. — A condition of weakness or exhaustion of the nervous system,
giving rise to various forms of mental and bodily inefficiency.
The term, an old one, but first popularized by Beard, covers an ill-defined,
motley group of symptoms, which may be either general and the expression
of derangement of the entire system, or local, limited to certain organs ; hence
the terms cerebral, spinal, cardiac, and gastric neurasthenia.
Etiology. — The causes may be grouped as hereditary and acquired.
(a) Hereditary. — We do not all start in life with the same amount of
nerve capital. Parents who have led irrational lives, indulging in excesses of
various kinds, or who have been the subjects of nervous complaints or of mental
GENERAL AND FUNCTIONAL DISEASES. 1087
trouble, may transmit to their children an organization which is defective in
what, for want of a better term, we must call " nerve force." Such individuals
start handicapped with a neuropathic predisposition, and furnish a consider-
able proportion of our neurasthenic patients. As van Gieson sonorously puts
it, " the potential energies of the higher constellations of their association
centres have been squandered by their ancestors."
Besides such forms of hereditary neuropathy, which we have to look upon
as instances of injury to the germ-plasm derived from one or both of the
parents, there have to be considered those cases in which during intra-uterine
life there have been conditions which interfered with the proper development
and nutrition of the embryo. So long as these individuals are content to trans-
act a moderate business with their life capital, all may go well, but there is
no reserve, and in the exigencies of modern life these small capitalists go under
and come to us as bankrupts.
(&) Acquired. — The functions, though perverted most readily in persons
who have inherited a feeble organization, may also be damaged in persons with
no neuropathic predisposition by exercise which is excessive in proportion to
the strength — i. e., by strain. The cares and anxieties attendant upon the
gaining of a livelihood may be borne without distress, but in many persons the
strain becomes excessive and is first manifested as worry. The individual loses
the distinction between essentials and non-essentials, trifles cause annoyance,
and the entire organism reacts with unnecessary readiness to slight stimuli,
and is in a state which the older writers called irritable weakness. If such
a condition be taken early and the patient given rest, the balance is quickly
restored. In this group may be placed a large proportion of the neurasthenics
which we see among business men, teachers, and journalists. Neurasthenia
may follow the infectious diseases, particularly influenza, typhoid fever, and
syphilis. The abuse of certain drugs, alcohol, tobacco, morphine may lead to
a high grade of neurasthenia, though the drug habit is more often a result
rather than a cause of the neurasthenia. Other causes more subtle, yet potent,
and less easily dealt with, are the worries attendant upon love affairs, religious
doubts, and the sexual passion. Sexual excesses have undoubtedly been exag-
gerated as a cause of neurasthenia, but that they are responsible in a number
of instances is certain.
The traumatic forms, especially those following upon railway accidents,
will be separately considered.
Symptoms. — These are extremely varied, and may be general or localized;
more often a combination of both. The appearance of the patient is sug-
gestive, sometimes characteristic, but difficult to describe. Important informa-
tion can be gained by the physician if he observe the patient closely as he
enters the room — the way he is clothed, the manner in which he holds his
body, his facial expression, and the humor which he is in. Loss of weight and
slight angemia may be present. The physical debility may reach a high grade
and the patient may be confined to bed. Mentally the patients are usually low-
spirited and despondent; women are frequently emotional.
The local s}Tnptoms may dominate the situation, and there have accordingly
been described a whole series of types of the disease — cerebral, spinal, cardio-
vascular, gastric, and sexual. In all forms there is a striking lack of accord-
ance between the symptoms of which the patient complains and the objective
1088 DISEASES OF THE NERVOUS SYSTEM.
changes discoverable by the j)hysician. In nearly every clinical type of the
disease the predominant symptoms are referable to pathological sensations and
the psychic effects of these. Imperfect sleep is also complained of by a majority
of patients^ or, if not complained of, is found to exist on inquiry.
In the cerebral or psychic form the sjonptoms are chiefly connected with
an inability to perform the ordinary mental work. Thus a row of fignires can
not be correctly added, the dictation or the writing of a few letters is a source
of the greatest worry, the transaction of petty details in business is a painful
effort, and there is loss of power of fixed attention. With this condition there
may be no headache, the appetite may be good, and the patient may sleep well.
As a rule, however, there are sensations of fulness and weight or flushes, if not
actual headache. Sleeplessness is a frequent concomitant of the cerebral form,
and may be the first manifestation. Some of these patients are good-tempered
and cheerful, but a majority are moody, irritable, and depressed.
Hypergesthesia, especially to sensations of pain, is one of the main charac-
teristics of almost all neurasthenic individuals. The sensations are nearly
always referred to some special region of the body — the skin, eye muscles, the
joints, the blood-vessels, or the viscera. It is frequently possible to localize
a number of points painful to pressure (Yalleix's points). In some pa-
tients there is marked vertigo, occasionally even resembling that of Meniere's
disease.
If such pathological sensations continue for a long time the mood and
character of the patient gradually alter. The so-called " irritable humor "
develops. Many obnoxiously egoistic individuals met with in daily- life are in
reality examples of psychic neurasthenia. Everything is complained of. The
patient demands the greatest consideration for his condition ; he feels that he
has been deeply insulted if his desires are not always immediately granted.
He may at the same time have but. little consideration for others. Indeed, in
the severer forms of the disease he may show a malicious pleasure in attempt-
ing to make people who seem happier than himself uncomfortable. Such
patients complain frequently that they are " misunderstood " by their fellows.
In many cases the so-called " anxiety conditions " gradually come on ; one
scarcely ever sees a case of advanced neurasthenia without the existence of
some form of " anxiety." In the simpler forms of anxiety (nosophobic) there
may be only a fear of impending insanity or of approaching death or of apo-
plexy. More frequently the anxious feeling is localized somewhere in the body
— in the precordial region, in the head, in the abdomen, in the thorax, or more
rarely in the extremities.
In some cases the anxiety becomes intense and the patients are restless, and
declare that they do not know what to do with themselves. They may throw
themselves upon a bed, crying and complaining, and making convulsive move-
ments with the hands and feet. Suicidal tendencies are not uncommon in
such cases, and patients may in desperation actually take their own lives.
Involuntary mental activity naay be very troublesome; the patient com-
plains that when he is overtired thoughts which he can not stop or control
run through his head with lightning-like rapidity. In other cases there is
marked absence of mind, the individual's mind being so filled up owing to
the overexcitability of latent memory pictures that he is unable to form the
proper associations for ideas called up by external stimuli. Sometimes a
GENERAL AND FUNCTIONAL DISEASES. 1089
patient complains that a definite word, a name, a numl^er, a melod}', or a song
keeps running in his head in spite of all he can do to abolish it.
In the severer cases of psychic neurasthenia the so-called " phobias " are
common. The most frequent form perhaps is agoraphobia^ in which patients
the moment they come into an open space are oppressed by an exaggerated
feeling of anxiety. They seem " frightened to death/' and commence to
tremble all over; they complain of compression of the thorax and palpitation
of the heart. They may break into profuse perspiration and assert that they
feel as though chained to the ground or that they can not move a step. It is
remarkable that in some such cases the open space can be crossed if the indi-
vidual be accompanied by some one, even by a child, or if he carry a stick or
an umbrella I Other people are afraid to be left alone (monophobia), espe-
cially in a closed compartment (claustrophobia).
The fear of people and of society is known as anthropophobia. A whole
series of other phobias have been described — batophobia, or the fear that high
things will fall; pathophobia, or fear of disease; siderodromophobia, or fear
of a railway journey; siderophobia or astrophobia, fear of thunder and light-
ning. Occasionally we meet with individuals who are afraid of everything and
every one — victims of the so-called pantophobia.
The special senses may be disturbed, particularly vision. An aching or
weariness of the eyeballs after reading a few minutes or flashes of light are
common symptoms. The " irritable eye," the so-called nervous or neurasthenic
asthenopia, is familiar to every family physician. According to Binswanger^
the essence of the asthenopic disturbance consists in pathological sensations
of fatigue in the ciliary muscles or the medial recti.
There may be acoustic disturbances — hyperalgesia and even true hyper-
acusia.
One of the most common of all the symptoms of neurasthenia is the pressure
in the head complained of by these patients. This symptom, variously de-
scribed, may be diffuse, but is more frequently referred to some one region —
frontal, temporal, parietal, or occipital.
When the spinal symptoms predominate — spinal irritation or spinal neuras-
thenia— in addition to many of the features just mentioned, the patients com-
plain of weariness on the least exertion, of weakness, pain in the back,
intercostal neuralgiform pains, and of aching pains in the legs. There may
be spots of local tenderness on the spine. The rachialgia may be spontaneous,
or may be noticed only on pressure or movement. Occasionally there may be
disturbances of sensation, particularly a feeling of numbness and tingling, and
the reflexes may be increased. Visceral neuralgias, especially in connection
with the genital organs, are frequently met with. The aching pain in the
back or in the back of the neck is the most constant complaint in these cases.
In women it is often impossible to say whether this condition is one of neuras-
thenia or hysteria. It is in these cases that the disturbances of muscular
activity are most pronounced, and in the French writings amyosthenia particu-
larly plays an important role. The symptoms may be irritative- or paretic, or
a combination of both. Disturbances of coordination are not uncommon in
the severer forms. These are particularly prone to involve the associated
movements of the eye muscles leading to asthenopic lack of accommodation.
Drooping of one eyelid is very common, probably owing to insufficient inner-
70 ■
1090 DISEASES OF THE NERVOUS SYSTEM.
vation on the part of the sympathetic rather than to paresis of the oculo-
motor nerve. Occasionally Eomberg's symptom may be present^ and the
patient, or even his physician, may fear a beginning tabes. More rarely there
is disturbance of such finely coordinated acts as writing and articulation, not
unlike those seen at the onset of general paresis. Such symptoms are always
alarming, and the greatest care must be taken in establishing a diagnosis.
That they may be the symptoms of pure neurasthenia, however, can no longer
be doubted.
The reflexes in neurasthenia are usually increased, the deep reflexes espe-
cially never being absent. The condition of the superficial reflexes is less
constant, though these, too, are usually increased. The pupils are often dilated,
and the reflexes are usually normal. There may be inequality of the pupils
in neurasthenia, a point which Pelizaeus has especially emphasized. Errors
in refraction are common, the correction of which may give great relief.
In another type of cases the muscular weakness is extreme, and may go on
even to complete motor helplessness. Very thorough examination is necessary
before deciding as to the nature of the affection, since in some instances serious
mistakes have been made. Here belong the atremia of Neftel, the akinesia
algera of Mobius, and the neurasthenic form of astasia ahasia described by
Binswanger.
In other cases the cardio-vascular symptoms are the most distressing, and
may occur with only slight disturbance of the cerebro-spinal functions, though
the conditions are nearly always combined. Palpitation of the heart, irregular
and very rapid action (neurasthenic tachycardia), and pains and oppressive
feelings in the cardiac region are the most common symptoms. The slightest
excitement may be followed by increased action of the heart, sometimes asso-
ciated with sensations of dizziness and anxiety, and the patients frequently
have the idea that they suffer from serious disease of this organ. Attacks of
pseudo-angina may occur.
Vaso-motor distur'bances constitute a special feature of many cases.
Flushes of heat, especially in the head, and transient hypersemia of the skin
may be very distressing symptoms. Profuse sweating may occur, either local
or general, and sometimes nocturnal. The pulse may show interesting features,
owing to the extreme relaxation of the peripheral arterioles. The arterial
throbbing may be everywhere visible, almost as much as in aortic insufficiency.
The pulse, too, may under these circumstances have a somewhat water-hammer
quality. The capillary pulse may be seen in the nails, on the lips, or on the
margins of a line drawn upon the forehead, and I have on several occasions
seen pulsation in the veins of the back of the hand. A characteristic symptom
in some cases is the throbbing aorta. This " preternatural pulsation in the
epigastrium," as Allan Burns calls it, may be extremely forcible and suggest
the existence of abdominal aneurism. The subjective sensations associated
with it may be very unpleasant, particularly when the stomach is empty.
In women especially, and sometimes in men, the peripheral blood-vessels
are contracted, the extremities are cold, the nose is red or blue, and the face
has a pinched expression. These patients feel much more comfortable when
the cutaneous vessels are distended, and resort to various means to favor this
(wearing of heavy clothing, use of diffusible stimulants).
The general features of gastro-intestinal neurasthenia have been dealt with
GENERAL AND FUNCTIONAL DISEASES. 1091
under the section of nervous dyspepsia. The connection of these cases with
dilatation of the stomach, floating kidney, and the condition which Glenard
calls enteroptosis has already been mentioned.
Sexual neurasthenia is a condition in which there is an irritable weakness
of the sexual organs manifested by nocturnal emissions, unusual depression
after intercourse, and often by a distressing dread of impotence. The mental
condition of these patients is most pitiable, and they fall an easy prey to
quacks and charlatans of all kinds.
Spermatorrhoea is the bugbear of the majority. They complain of con-
tinued losses, usually without accompanying pleasurable sensations. After
defecation or micturition there may be seminal discharges. Microscopic ex-
amination sometimes reveals the presence of spermatozoa. Actual nervous
impotence is not uncommon. The " painful testicle " is a well-known neuras-
thenic phenomenon. In the severer cases, especially those bearing the stig-
mata of degeneration, there may be evidence of sexual perversion.
In females it is common to find a tender ovary, and painful or irregular
menstruation.
In all forms of neurasthenia the condition of the urine is important.
Many cases are complicated with the symptoms of the condition known as
lithsemia, and so marked may this be that some have indeed made a special
form of lithsemic neurasthenia. Polyuria may be present, but is more com-
mon in hysteria. With disturbed digestion the urates and oxalates may be
in excess.
Diagnosis. — PsycJiasthenia. — ^TJnder this term Janet would separate from
neurasthenia the cases characterized by mental, emotional, and physical dis-
turbances, imperative ideas, phobias of all sorts, doubts, enfeebled will, imcon-
trollable movements, and many of the borderland features of the insanity of
young persons. It is really an inherited psychoneurosis, while neurasthenia
is usually acquired. Obsessions of all sorts characterize the condition and
there may be a feeling of unreality and even of loss of personality. How com-
plicated the condition may be is shown from the following varieties distin-
guished by Janet: (1) The doubter, in whom obsessive ideas are not very
precise, more of the nature of a general indication rather than a specific idea,
such as a craze for research, for explanation, for computing. (2) The scru-
pulous, whose obsessions are of a moral nature. Their manias are of literal-
ness of statement, of exact truth, of conjuration, of reparation, of symbols,
etc. (3) The criminal, whose obsessive ideas are of homicide, theft, and other
overt acts. The impulsive idea is stronger in this than in the other varieties.
(4) The inebriates, dipsomaniac, morphinomaniac, etc., in whom the impulse
seems to be least resistible. (5) The genesically perverted. (6) Delirious
psychasthenia, a condition in which a delirious state of mind occurs, connected
with the obsession.
The anxiety conditions and various phobias, as well as the difEerent
varieties of tic and the occupation neuroses when they accompany neuras-
thenia, are regarded as complications dependent in the majority of instances
upon faulty heredity.
Neurasthenia is a disease above all others which has to be diagnosed from
the subjective statements of the patient, and from an observation of his general
behavior rather than from the physical examination. The physical examina-
1092 DISEASES OF THE NERVOUS SYSTEM.
tion is of the highest importance in excluding other diseases likely to be
confounded with it. That somatic changes occur and that physical signs are
often to be made out is very true, and we owe to Lowenfeld especially a careful
discussion of these points, but there is nothing typical or pathognomonic in
these objective changes.
The hj-pochondriac differs from the neurasthenic in the excessive psychic
distortion of the pathological sensations to which he is subject. He is the
victim of actual delusions regarding his condition.
The confusion of neurasthenia with hj'Steria is still more frequent; in
women especially a diagnosis of hysteria is often made when in reality the
condition is one of neurasthenia. In the absence of hysterical paroxj^sms, of
crises, and of those marked emotional and intellectual characteristics of the
hysterical individual the diagnosis of hysteria should not be made. Of course,
in many of the cases of hysteria definite hysterical stigmata (hysterical paral-
yses, convulsions, contractures, anaesthesias, alterations in the visual field, etc.)
are present, and the diagnosis is not difficult.
Epilepsy is not likel}* to be confounded with neurasthenia if there be defi-
nite epileptic attacks, but the cases of petit mal may be puzzling.
The onset of exophthalmic goitre may be mistaken for neurasthenia, espe-
cially if there be no exophthalmos at the beginning. The emotional disturb-
ances and the irritability of the heart may mislead the physician. In pro-
nounced cases of nervous prostration the differential diagnosis from the various
psychoses may be extremely difficult.
The two forms of organic disease of the nervous system with which neuras-
thenia is most likely to be confounded are tabes and general paresis. The
s}Tnptoms of the spinal form of neurasthenia may resemble those of the former
disease, while the s}Tnptoms of the psychic or cerebral form of neurasthenia
may be very similar to those of general paresis. The diagnosis, as a rule,
presents no difficulty if the physician be careful to make a thorough routine
examination. It is only the superficial study of a case that is likely to lead
one astray. In tabes especially a consideration of the sensory disturbances,
of the deep reflexes, and of the pupillary findings will always establish the
presence or absence of the disease. In general paresis there is sometimes more
difficult}^ The onset of general paresis is often characterized by the appear-
ance of symptoms quite like those of ordinary neurasthenia, and the family
physician may entirely overlook the grave nature of the malady. The mistake
in the other direction is, however, perhaps just as common. A physician who
once or twice has seen a case of general paresis arise out of what appeared to
be one of pronounced neurasthenia is too prone afterward to suspect every
neurasthenic to be developing the malign affection. The most marked symp-
toms, however, of psychic exhaustion do not jilstify a diagnosis of general
paresis even when the history is suspicious, unless along with it there is a
definite paresis of the pupils, of the facial muscles, or of the muscles of articu-
lation. A history of syphilis or of chronic alcoholism or morphinism asso-
cated with severe psychic exhaustion should, of course, put one always on his
guard, and the physician should be sharply on the lookout for the appearance
of intellectual defects, paraphasia, facial paresis, and sluggishness of the pupils.
Treatment. — Prophylaxis. — Many patients come under our care a gen-
eration too late for satisfactory treatment, and it may be impossible to restore
GENERAL AND FUNCTIONAL DISEASES. 1093
the exhausted capital. The greatest care should be taken in the rearing of
children of neuropathic predisposition. From a very early age they should
be submitted to a process of " psychic hardening," every effort being made to
strengthen the bodily and mental condition. Even in infancy the child should
not be pampered. Later on the greatest care should be exercised with regard
to food, sleep, and school v^^ork. Complaints of children should not be too
seriously considered.
Much depends upon the example set by the parents. A restless, emotional,
constantly complaining mother will rack the nervous system of a delicate child.
In some instances, for the welfare of a developing boy or girl, the physician
may find it necessary to advise its removal from home.
Neurotic children are especially liable during development to fits of temper
and of emotional disturbance. These should not be too lightly considered.
Above all, violent chastisement in such cases is to be avoided, and loss of
temper on the part of the parent or teacher is particularly pernicious for the
nervous system of the child. Where possible, in such instances, the best treat-
ment is to put the obstreperous child immediately to bed, and if the excite-
ment and temper continue a warm bath followed by a cool douche may be
effective. If he be put to bed after the bath sleep soon follows.
Special attention is necessary at puberty in both boys and girls. If there
be at this period any marked tendency to emotional disturbance or to intel-
lectual weakness the child should be removed from school and every care taken
to avoid unfavorable influences.
Peesonal Hygiene. — Throughout life individuals of neuropathic predis-
position should obey scrupulously certain hygienic and prophylactic rules. In-
tellectual work especially should be judiciously limited and should alternate
frequently with periods of repose. Excitement of all kinds should of course
be avoided, and such individuals will do well to be abstemious in the use of
tobacco, tea, coffee, and alcohol, if, indeed, they be permitted to use these
substances at all. The habit, happily becoming very common, of taking at
least once a year a prolonged holiday away from the ordinary environment,
in the woods, in the mountains, or at the seashore, should be urgently en-
joined upon every neuropathic individual. In many instances it is found to
be the greatest relief and rest if the patient can take his holiday away from
his relatives.
During ordinary life nervous people should, during some portion of each
day, pay rational attention to the body. Cold baths, swimming, exercises in
the gymnasium, gardening, golf, lawn tennis, cricket, hunting, shooting, row-
ing, sailing, and bicycling are of value in maintaining the general nutrition.
Such exercises are, of course, to be recommended only to individuals physically
equal to them. If neurasthenia be once well established the greatest care must
be observed in the ordering of exercise. Many nervous girls have been com-
pletely broken down by following injudicious advice with regard to long walks.
Treatment of the Condition. — The treatment of neurasthenia when
once established presents a varied problem to the thoughtful physician. Every
case must be handled upon its own merits, no two, as a rule, requiring exactly
the same methods. In general it will be the aim of the medical adviser to
remove the patient as far as possible from the influences which have led to
his downfall, and to restore to normal the nervous mechanisms which have
1094 DISEASES OF THE NERVOUS SYSTEM.
been weakened by injurious influences. The general character of the indi-
vidual, his physical and social status must of course be considered, and the
therapeutic measures carefully adjusted to these.
The diagnosis having been settled, the physician may assure the patient
that with jDrolonged treatment, during which his cooperation with the physi-
cian is absolutely essential, he may expect to get well. He must be told that
much depends upon himself and that he must make a vigorous efEort to over-
come certain of his tendencies, and that all his strength of will will be needed
to further the progress of the cure. In the case of business or professional
men, in whom the condition develops as a result of overwork or overstudy, it
may be sufficient to enjoin absolute rest with change of scene and diet. A trip
abroad, with a residence for a month or two in Switzerland, or, if there are
sjanptoms of nervous dyspepsia, a residence at one of the Spas will usually
prove sufficient. The excitement of the large cities abroad should be avoided.
The longer the disease has lasted and the more intense the symptoms have
been, the longer the time necessary for the restoration of health. In cases of
any severity the patient must be told that at least six months' complete ab-
sence from business, under strict medical guidance, will be necessary. Shorter
periods may of course be of benefit, which, however, as a rule, will be only
temporary.
It will often be found advisable to make out a daily programme, which
shall occupy almost the whole time of the patient. At first he need Iniow
nothing about this, the case being given over entirely to the nurse. As im-
provement advances, moderate physical and intellectual exercises, alternating
frequently with rest and the administration of food, may be undertaken. Some
one hour of the day may be left free for reading, correspondence, conver-
sation, and games. In some instances the writing of letters is particularly
harmful to the patient and must be prohibited or limited. Cultured indi-
viduals may find benefit from attention to drawing, painting, modelling,
translating from a foreign language, the making of abstracts, etc., for short
periods in the day.
In not a few cases, including a large proportion of neurasthenic women,
a S3^stematic "Weir Mitchell treatment rigidly carried out should be tried (see
H3^steria). For obstinate and protracted cases, particularly if combined with
the chloral or morphia habit, no other plan is so satisfactory. The patient
must be isolated from his friends, and any regulations undertaken must be
strictly adhered to, the consent of the patient and his family having first been
gained. If the case responds well to the treatment there should be a gain of
from 2 to 4 pounds per week. The benefit is often extraordinary, individuals
increasing in weight as much as from 50 to 80 pounds in the course of twelve
weeks. The treatment of the gastric and intestinal symptoms so important
in this condition has already been considered. For the irregular pains, par-
ticularly in the back and neck, the thermo-cautery is invaluable.
Hydrotherapy is indicated in nearly every case if it can be properly applied.
Much can be done at home or in an ordinary hospital, but for systematic
hydrotherapeutic treatment residence in a suitable sanitarium is necessary.
I have found the wet pack of especial value. Particularly at night, in cases of
sleeplessness, it is perhaps the best remedy against insomnia we have. Some
patients gain rapidly in weight through the systematic use of the wet pack.
GENERAL AND FUNCTIONAL DISEASES. 1095
Salt baths are more helpful to some patients. The various forms of douches,
partial packs, foot baths, etc., may be valuable in individual cases. The Scotch
douche is often invigorating in the milder cases.
Electrotherapy is of some value, though only in combination with psychic
treatment and hydrotherapy. General and local faradization, galvanic elec-
tricity, and Franklinization may be used; in every case, however, with great
caution and only by skilled operators. The care of the eyes is most important,
and refractive errors should be corrected.
Treatment by drugs should be avoided as much as possible. They are of
benefit chiefly in the combating of single symptoms. A placebo is sometimes
necessary for its psychic effect. Alcohol, morphia, chloral, or cocaine should
never be given. The family physician is often responsible for the develop-
ment of a drug habit. I have been repeatedly shocked by the loose, careless
way in which physicians inject, morphia for a simple headache or a mild
neuralgia.
General tonics may be helpful, especially if the individual be anaemic.
Arsenic and more often iron are then indicated. The value of phosphorus has
been exaggerated. For the severer pains and nervous attacks some sedative
may occasionally be necessary, esj)ecially at the beginning of the treatment.
The bromides, especially a mixture of the salts of ammonium, potassium, and
sodium may here be given with advantage. An occasional dose of phenacetin,
antipyrin, or salipyrin may be required, but the less of these substances we can
get along with the better. For the relief of sleeplessness all possible measures
should be resorted to before the employment of drugs. The wet pack will
usually suffice. If absolutely necessary to give a drug, sulphonal, trional, or
amylene hydrate may be employed.
In cases in which the anxiety conditions are disturbing, the cautious use
of opium in pill form may be necessary, since, as in the psychoses, opium here
will sometimes yield permanent relief. A prolonged treatment with opium is,
however, never necessary in neurasthenia.
Faith Healing. — In all ages, and in all lands, the prayer of faith, to
use the words of St. James, has healed the sick ; and we must remember that
amid the iEsculapian cult, the most elaborate and beautiful system of faith
healing the world has seen, scientific medicine took its rise. As a profession,
consciously or unconsciously, more often the latter, faith has been one of our
most valuable assets, and Galen expressed a great truth when he said, " He
cures most successfully in whom the people have the greatest confidence."
It is in these cases of neurasthenia and psychasthenia, the weak brothers and
the weak sisters, that the personal character of the physician comes into play,
and once let him gain the confidence of the patient, he can work just the
same sort of miracles as Our Lady of Lourdes or Ste. Anne de Beaupre. Three
elements are necessary: first, a strong personality in whom the individual
has faith — Christ, Buddha, iEsculapius (in the days of Greece), one of the
saints, or, what has served the turn of common humanity very well, a physi-
cian. Secondly, certain accessories — a shrine, a sanctuary, the service of a
temple, or for us a hospital or its equivalent, with a skilful nurse. Thirdly,
suggestion, either of the " only believe," " feel it," " will it " attitude of mind,
which is the essence of every cult and creed, or of the active belief in the
assurance of the physician that the precious boon of health is within reach.
1096 DISEASES OF THE NERVOUS SYSTEM.
XIII. THE TRAUMATIC NEUROSES.
(Railway Brain and Railway Spine ; Traumatic Hysteria.)
Definition. — A morbid condition following shock which presents the symp-
toms of neurasthenia or hysteria or of both. The condition is kno^vn as
" railway brain " and " railway spine.^'
Erichsen regarded the condition as the result of inflammation of the men-
inges and cord, and gave it the name railway spine. Walton and J. J. Putnam,
of Boston, were the first to recognize the hysterical nature of many of the cases,
and to Westphal's pupils we owe the name traumatic neurosis. For an ex-
cellent discussion of the whole question the reader is referred to Pearce Baily's
work, On Accident and Injury; their Eelation to Diseases of the Nervous
System.
Etiology. — The condition follows an accident, often in a railway train, in
which injury has been sustained, or succeeds a shock or concussion, from which
the patient may apparently not have suffered in his body. A man may appear
perfectly well for several days, or even a week or more, and then develop the
symptoms of the neurosis. Bodily shock or concussion is not necessary. The
affection may follow a profound mental impression; thus, an engine-driver
ran over a child, and received thereby a very severe shock, subsequent to which
the most pronounced symptoms of neurasthenia developed. Severe mental
strain combined with bodily exposure may cause it, as in a case of a naval
officer who was wrecked in a violent storm and exposed for more than a day
in the rigging before he was rescued. A slight blow, a fall from a carriage
or on the stairs may suffice.
Symptoms. — The cases may be divided into three groups : simple neuras-
thenia, cases Avith marked hysterical manifestations, and cases with severe
symptoms indicating or simulating organic disease.
(a) Simple Traumatic Neurasthenia. — The first symptoms usually de-
velop a few weeks after the accident, which may or may not have been asso-
ciated with an actual trauma. The patient complains of headache and tired
feelings. He is sleepless and finds himself unable to concentrate his attention
properly upon his work. A condition of nervous irritability develops, which
may have a host of trivial manifestations, and the entire mental attitude of
the person may for a time be changed. He dwells constantly upon his condi-
tion, gets very despondent and low-spirited, and in extreme cases melancholia
may develop. He may complain of numbness and tingling in the extremities,
and in some cases of much pain in the back. The bodily functions may be well
performed, though such patients usually have, for a time at least, disturbed
digestion and loss in weight. The physical examination may be entirely nega-
tive. The reflexes are slightly increased, as in ordinary neurasthenia. The
pupils may be unequal ; the cardio-vascular changes already described in neu-
rasthenia may be present in a marked degree. According as the symptoms are
more spinal or more cerebral, the condition is known as railway brain or rail-
way spine.
(2) Cases with Marked Hysterical Features. — Following an injury
of any sort, neurasthenic symptoms, like those described above, may develop.
GENERAL AND FUNCTIONAL DISEASES. 1097
and in addition symptoms regarded as characteristic of hysteria. The emo-
tional element is prominent, and there is but slight control over the feelings.
The patients have headache, backache, and vertigo. A violent tremor may be
present, and indeed constitutes the most striking feature of the case. In the
case of an engineer who developed subsequent to an accident a series of
nervous phenomenon, the most marked feature was an excessive tremor of
the entire body, which was specially manifest during emotional excitement.
The most pronounced hysterical symptoms are the sensory disturbances. As
first noted by Putnam and Walton, hemianaesthesia may occur as a sequence
of traumatism. This is a common symptom in France, but rare in England
and in the United States. Achromatopsia may exist on the anaesthetic side.
A second, more common, manifestation is limitation of the field of vision,
similar to that which occurs in hysteria.
Eemarkable disturbances may develop in some of these cases. I once saw
a man who had been struck by an electric car, whose chief symptom was an
extraordinary increase in the number of respirations. He was a stout, power-
fully built man, and presented practically no other symptom than dyspnoea
of the most extreme grade. At the time of observation his respirations were
over 130 per minute, and he stated that they had been counted at over 150.
(3) Cases in which the Symptoms suggest Organic Disease of the
Brain and Cord. — As a result of spinal concussion, without fracture or ex-
ternal injury, there may subsequently develop symptoms suggestive of organic
disease, which may come on rapidly or at a late date. In a case reported by
Leyden the symptoms following the concussion were at first slight and the
patient was regarded as a simulator, but finally the condition became aggra-
vated and death resulted. The post mortem showed a chronic pachymenin-
gitis, which had doubtless resulted from the accident. The cases in this group
about which there is so much discussion are those which display marked sen-
sory and motor changes. Following an accident in which the patient has not
received external injury a condition of excitement may develop within a week
or ten days; he complains of headache and backache, and on examination
sensory disturbances are found, either hemianaesthesia or areas on the skin in
which the sensation is much benumbed ; or painful and tactile impressions may
be distinctly felt in certain regions, and the temperature sense is absent. The
distribution may be bilateral and symmetrical in limited regions or hemiplegic
in type. Limitation of the field of vision is usually marked in these cases,
and there may be disturbance of the senses of taste and smell. The superficial
refiexes may be diminished; usually the deep reflexes are exaggerated. The
pupils may be unequal; the motor disturbances are variable. The French
writers describe cases of monoplegia with or without contracture, symptoms
upon which Charcot lays great stress as a manifestation of profound hysteria.
The combination of sensory disturbances — anaesthesia or hyperaesthesia — with
paralysis, particularly if monoplegic, and the occurrence of contractures with-
out atrophy and with normal electrical reactions, may be regarded as distinct-
ive of hysteria.
In rare cases following trauma and succeeding to symptoms which may
have been regarded as neurasthenic or hysterical, there are organic changes
which may prove fatal. That this sequence occurs is demonstrated clearly
by recent post-mortem examinations. The features upon which the greatest
71
1098 DISEASES OF THE NERVOUS SYSTEAi.
reliance can be placed as indicating organic change are optic atrophy, bladder
sjonptoms, particularly in combination with tremor^ paresis, and exaggerated
reflexes.
The anatomical changes in this condition have not been very definite.
When death follows spinal concussion within a few days there may be no
apparent lesion, but in some instances the brain or cord has shown puncti-
form liEemorrhages. Edes has reported 4 cases in which a gradual degeneration
in the pyramidal tracts followed concussion or injury of the spine ; but in all
these cases there was marked tremor and the spinal symptoms developed early,
or followed immediately upon the accident. Autopsies upon cases in which
organic lesions have supervened upon a traumatic neurosis are extremely rare.
Diagnosis. — A condition of fright and excitement following an accident
may persist for days or even weeks, and then gradually pass away. The symp-
toms of neurasthenia or of hysteria which subsequently develop present nothing
peculiar and are identical with those which occur under other circumstances.
Care must be taken to recognize simulation, and, as in these cases the condition
is largely subjective, this is sometimes extremely difficult. In a careful exam-
ination a simulator will often reveal himself by exaggeration of certain symp-
toms, particularly sensitiveness of the spine, and by increasing voluntarily the
reflexes. Maunkopif suggests as a good test to take the pulse-rate before, dur-
ing, and after pressure upon an area said to be painful. If the rate is quick-
ened, it is held to be proof that the pain is real. This is not, however, always
the case. It may require a careful study of the case to determine whether the
individual is honestly suffering from the symptoms of which he complains.
A still more important question in these cases is. Has the patient organic dis-
ease? The symptoms given under the first two groups of cases may exist in
a marked degree and may persist for several years without the slightest evidence
of organic change. Hemiansesthesia, limitation of the field of vision, mono-
plegia with contracture, may all be present as hysterical manifestations, from
which recovery may be complete. In our present knowledge the diagnosis of
an organic lesion should be limited to those cases in which optic atrophy, blad-
der troubles, and signs of sclerosis of the cord are well marked — indications
either of degeneration of the lateral columns or of multiple sclerosis.
Prognosis. — A majority of patients with traumatic hysteria recover. In
railway cases, so long as litigation is pending and the patient is in the hands
of lawyers the symptoms usually persist. Settlement is often the starting-point
of a speedy and perfect recovery. I have known return to health after the
persistence of the most aggravated symptoms with complete disability of from
three to five years' duration. On the other hand, there are a few eases in which
the symptoms persist even after the litigation has been closed ; the patient goes
from bad to worse and psychoses develop, such as melancholia, dementia, or
occasionally progressive paresis. And, lastly, in extremely rare cases, organic
lesions may occur as a sequence of the traumatic neurosis.
The function of the physician acting as medical expert in these cases con-
sists in determining (a) the existence of actual disease, and (h) its character,
whether simple neurasthenia, severe hysteria, or an organic lesion. The out-
look for ultimate recovery is good except in cases which present the more seri-
ous symptoms above mentioned. Nevertheless, it must be borne in mind that
traumatic hysteria is one of the most intractable affections which we are called
GENERAL AND FUNCTIONAL DISEASES. 1099
upon to treat. In the treatment of the traumatic neuroses the practitioner
may be guided by the principles laid down in the preceding chapter, in which
the treatment of neurasthenia in general has been described.
XIV. OTHER FORMS OF FUNCTIONAL PARALYSIS.
I. Periodical Paralysis.
The periodical paralysis of the ocular muscles, which may recur for years,
has already been referred to. A periodical paralysis involving the general
muscles, also a " family " aflEection, may return with great regularity. Gold-
flam described twelve cases in one family, the heredity being through the
mother. In the United States E. W. Taylor described eleven cases in one
family in five generations. Holtzapple, of York, Pa., reports 16 cases in one
family. Six of the number died in an attack.
The clinical picture is similar in all recorded cases. The paralysis involves,
as a rule, the arms and legs, but may be general below the neck. It comes on
in healthy persons without apparent cause, and often during sleep. At first
there may be weakness of the limbs, a feeling of weariness and sleepiness, but
rarely sensory symptoms. The paralysis, beginning in the legs, to which it
may be confined, is usually complete within the first twenty-four hours. The
neck muscles are sometimes involved, and occasionally those of the tongue and
pharynx. The cerebral nerves and the special senses are, as a rule, unaffected.
The temperature is normal or subnormal and the pulse slow. The deep re-
flexes are diminished, sometimes abolished, and the skin reflexes may be
enfeebled. A most remarkable feature is the extraordinary reduction or com-
plete abolition of the'faradic excitability of both muscles and nerves.
Improvement begins within a few hours or a day or two, the paralysis
disappearing completely and the patient becoming perfectly well. The attacks
usually recur at intervals of one to two weeks, but they may return daily.
They generally cease after the fiftieth year. There may be signs of acute
dilatation of the heart during the attack. In the three cases reported by
J. K. Mitchell, Flexner, and Edsall, a diminished kreatinin excretion for
several days before and at the beginning of a seizure was repeatedly found.
There was a rise to normal after the attacks. Potassium citrate in full doses
either shortened or aborted the paralyses,
II. Astasia; Abasia.
These terms, indicating respectively inability to stand and inability to
walk, have been applied by Charcot and Blocq to diseased conditions charac-
terized by loss of the power of standing or of walking, with retention of
muscular power, coordination, and sensation. Blocq's definition is as follows:
" A morbid state in which the impossibility of standing erect and walking
normally is in contrast with the integrity of sensation, of muscular strength,
and of the coordination of the other movements of the lower extremities." The
condition forms a symptom group, not a morbid entity, and is probably a func-
tional neurosis. Knapp in his monograph analyzes the 50 cases reported in
the literature. Twenty-five of these were in men, 25 in women. In 21 cases
hysteria was present ; in 3, chorea ; in 2, epilepsy ; and in 4, intention psychoses.
1100 DISEASES OF THE NERVOUS SYSTEM.
As a rule, the patients, though able to move the feet and legs perfectly when
in bed, are either unable to walk properly or can not stand at all. The dis-
turbances have been very varied, and different forms have been recognized.
The commonest, according to Knapp's analysis of the recorded cases, is the
paralytic, in which the legs give out as the patient attempts to walk and " bend
under him as if made of cotton." " There is no rigidity, no spasm, no inco-
ordination. In bed, sitting, or even while suspended, the muscular strength
is found to be good." Other cases are associated with spasm or ataxia; thus
there may be movements which stiffen the legs and give to the gait a somewhat
spastic character. In other instances there are sudden flexions of the legs, or
even of the arms, or a saltatory, spring-like spasm. In a majority of the cases
it is a manifestation of a neurosis allied to hysteria.
The cases, as a rule, recover, particularly in young persons. Kelapses are
not uncommon. The rest treatment and static electricity should be employed.
H. YASO-MOTOR AND TROPHIO DISORDERS.
I. RAYNAUD'S DISEASE.
Definition. — A vascular disorder, probably dependent upon vaso-motor in-
fluences, characterized by three grades of intensity: (a) Local syncope, (&)
local asphyxia, and (c) local or symmetrical gangrene.
Local Syncope. — This condition is seen most frequently in the extremi-
ties, producing the condition knovm as dead fingers or dead toes. It is analo-
gous to that produced by great cold. The entire hand may be affected with
the fingers; more commonly only one or more of the fingers. This feature of
the disease rarely occurs alone, but is generally associated with local asphyxia.
The common sequence is as follows : On exposure to slight cold or in conse-
quence of some emotional disturbance the fingers become white and cold, or
both fingers and toes are affected. The pallor may continue for an indefinite
time, though usually not more than an hour or so; then gradually a reaction
follows and the fingers get burning hot and red. This does not necessarily
occur in all the fingers together; one finger may be as white as marble, while
the adjacent ones are of a deep red or plum color.
Local Asphyxia. — Chilblains form the mildest grade of this condition.
It usually follows the local syncope, but it may come on independently. The
fingers and toes are of tenest affected, next in order the ears ; more rarely por-
tions of the skin on the arms and legs. During an attack the fingers alone,
sometimes the hands, also swell and become intensely congested. In the most
extreme grade the fingers are perfectly livid, and the capillary circulation is
almost stagnant. The swelling causes stiffness and usually pain, not acute,
but due to the distention of the skin. Sometimes there is marked ansesthesia.
Pain of a most excruciating kind may be present. Attacks of this sort may
recur for years, and be brought on by the slightest exposure to cold or in
consequence of disturbances, either mental or, in some instances, gastric.
Apart from this unpleasant symptom the general health may be very good.
The condition is always worse during the winter, and may be present only
when the external temperature is low.
VASO-AIOTOR AND TROPHIC DISORDERS. 1101
Local or Symmetrical Gangrene. — The mildest grade of this condition
follows the local asphyxia, in the chronic cases of which small necrotic areas
are sometimes seen at the tips of the fingers. Sometimes the pads of the
fingers and of the toes are quite cicatricial from repeated slight losses of this
kind. So also when the ears are affected there may be superficial loss of sub-
stance at the edge. The severer cases, which terminate in extensive gangrene,
are fortunately rare.
In an attack the local asphyxia persists in the fingers. The terminal pha-
langes, or perhaps the end of only one finger, become black, cold, and insen-
sible. The skin begins to necrose and superficial gangrenous blebs appear.
Gradually a line of demarkation shows itself and a portion of one or more of
the fingers sloughs away. The resulting loss of substance is much less than the
appearance of the hand or foot would indicate, and a condition which looks
as if the patient would lose all the fingers or half of a foot may result perhaps
in only a slight superficial loss in the phalanges. In severer cases the greater
portion of a finger or the tip of the nose may be lost. Occasionally the disease
is not confined to the extremities, but affects symmetrical patches on the limbs
or trunk, and may pass on to rapid gangrene. These severe types of cases
occur particularly in young children, and death may result within three
or four days. The attacks are usually very painful, and the motion of the
part is much impaired. In some cases numbness and tingling persist for a
long time.
The climax of this series of neuro-vascular changes is seen in the remark-
able instances of extensive multiple gangrene. They are most common in
children, and may progress with frightful rapidity. In the Medico-Chirurgical
Society^s Transactions, vol. xxii, there is an extraordinary case reported, in
which the child, aged three, lost in this way both arms above the elbow, and
the left leg below the knee. There also had been a spot of local gangrene on
the nose. Spontaneous amputation occurred, and the child made a complete
recovery. The cases are more frequent than has been supposed, and an illus-
tration is given by Weeks, of Marion, Ohio, in which the boy had rheumatic
pains in the legs, and purpuric blotches developed before the gangrene began
(Medico- Surgical Bulletin, July 1, 1894).
There are remarkable concomitant symptoms in Eaynaud's disease to which
a good deal of attention has been paid of late years. Hasmoglobinuria may
occur during an attack, or may take the place of it. In such instances the
affection is usually brought on by cold weather. In a case reported by H. M.
Thomas from my clinic, Eaynaud's disease occurred for three successive win-
ters and always in association with hsemoglobinuria. The attacks were some-
times preceded by a chill. Several cases of the kind are found in Barlow's
appendix to his translation of Eaynaud's paper for the New Sydenham Society.
The onset with a chill, as in the case just mentioned, has doubtless given rise
to the idea that the disease is in some way associated with ague. Cerebral
symptoms, particularly mental torpor and transient loss of consciousness,
have also been noticed in some cases. The case just mentioned with hsemo-
globinuria had epilepsy with the attacks. Exposure on a cold day would bring
on an epileptic seizure with the local asphyxia and bloody urine. Another
patient, the subject for years of Eaynaud's disease, had many attacks of tran-
sient hemiplegia on one side or the other, when on the right side with
1102 DISEASES OF THE NERVOUS SYSTEM.
aphasia. She finally died in an attack. Occasionally joint affections develop,
particularly anchylosis and thickening of the phalangeal articulations.
Southey has reported a case in which mania developed, and Barlow an in-
stance in which the woman had delusions. Peripheral neuritis has been found
in several cases.
Pathology. — The patholog}^ of this remarkable disease is still obscure. Eay-
naud suggested that the local s3^ncope was produced by a vascular spasm, which
seems likely. The aspliyxia is dependent upon dilatation of the capillaries and
small veins, probably with the persistence of some degree of spasm of the
smaller arteries. There are two totally different forms of congestion, which
ma}" be shown in adjacent fingers; one may be swollen, of a vivid red color,
extremely hot, the capillaries and all the vessels fully distended, and the antemia
produced by pressure may be instantaneously obliterated; the adjacent finger
may be equally swollen, absolutely cyanotic, stone cold, and the anaemia pro-
duced by pressure takes a long time to disappear. In the latter case the
arterioles are probably still in a condition of spasm. Monro's monograph may
be consulted for additional details.
Treatment. — In many cases the attacks recur for years uninfluenced by
treatment. Mild attacks require no treatment. In the severer forms of local
asph3':s:ia, if in the feet, the patient should be kept in bed with the legs elevated.
The toes should be wrapped in cotton-wool. The pain is often very intense
and may require morphia. Carefully applied, systematic massage of the ex-
tremities is sometimes of benefit. Galvanism may be tried. Barlow advises
immersing the afEected limb in salt water and placing one electrode over the
spine and the other in the water. Xitroglycerin has been warmly recommended
by Gates. Gushing has introduced a plan of treatment with the tourniquet
which has proved very successful in several cases in my wards. The elastic
bandage, or, better, one of his pneumatic tourniquets, is applied to an extrem-
itj tight enough to shut off the arterial circulation and left for some minutes.
On releasing the constriction the member flushes brightly, owing to the vaso-
motor relaxation. The application in cases of severe spasm may have to be
repeated at frequent intervals before the vascular constriction in the affected
parts will be overcome, and the normal temperature and color return in them.
II. ERYTHROMELALGIA (Red Neuralgia).
Definition. — " A chronic disease in which a part or parts — usually one or
more extremities — suffer with pain, flushing, and local fever, made far worse
if the parts hang down" (Weir Mitchell). The name signifies a painful, red
extremity.
Symptoms. — In 1872 (Phila. Med. Times, Xovember 23d), in a lecture on
certain painful affections of the feet. Weir Mitchell described the case of a
sailor, aged forty, who after an African fever began to have " dull, heavy pains,
at first in the left and soon after in the right foot. There was no swelling at
first. When at rest he was comfortable and the feet were not painful. After
walking the feet were swollen. They scarcely pitted on pressure, but were
purple with congestion; the veins were ever}^where singularly enlarged, and
the arteries were throbbing visibly. The whole foot was said to be aching and
burning, but above the ankle there was neither swelling, pain, nor flushing."
VASO-MOTOR AND TROPHIC DISORDERS. 1103
As the weather grew cool he got relief. Nothing seemed to benefit him. This
brief summary of Mitchell's first case gives an accurate clinical picture of the
disease. Plis second communication, On a Eare Vaso-motor Neurosis of the
Extremities, appeared in the Am. Jour, of the Medical Sciences for July, 1878,
while in his Clinical Lessons on Nervous Diseases, 1897, will be found addi-
tional observations.
The disease is rare. Eost states that there are only about 40 instances in
the literature. The feet are much more often affected than the hands. The
pain may be of the most atrocious character. It is usually, but not always,
relieved by cool weather ; in one of my cases the winter aggravates the trouble.
In a few cases (Eisner, Dehio, Eolleston) the affection has been complicated
with Eaynaud's disease.
Mitchell speaks of it as a " painful nerve-end neuritis." Dehio suggests
that there may be irritation in the cells of the ventral horns of the cord at
certain levels. Excision of the nerves passing to the parts has been followed,
by relief. In one of Mitchell's cases gangrene of the foot followed excision
of four inches of the musculo-cutaneous nerve and stretching of the posterior
tibial. Sclerosis of the arteries was found. Of the 9 cases in which the local
conditions were studied anatomically, the only constant change was a chronic
endarteritis (Batty Shaw).
III. ANGIO-NEUROTIC (EDEMA (auincke's Disease).
Definition. — An affection characterized by the occurrence of local ocdema-
tous swellings, more or less limited in extent, and of transient duration.
Severe colic is sometimes associated with the outbreak. There is a marked
hereditary disposition in the disease.
Symptoms. — The oedema appears suddenly and is usually circumscribed.
It may appear in the face ; the eyelid is a common situation ; or it may involve
the lips or cheek. The backs of the hands, the legs, or the throat may be
attacked. Usually the condition is transient, associated perhaps with slight
gastro-intestinal distress, and the affection is of little moment. There may be
a remarkable periodicity in the outbreak of the oedema. In Matas' case this
periodicity was very striking ; the attack came on every day at eleven or twelve
o'clock. The disease may be hereditary through many generations. In the
family whose history I reported, five generations had been affected, including
twenty-two members. The swellings appear in various parts; only rarely are
they constant in one locality. The hands, face, and genitalia are the parts
most frequently affected. Itching, heat, redness, or in some instances urti-
caria, may precede the outbreak. Sudden oedema of the lar3aix may prove
fatal. Two members of the family just referred to died of this complication.
In one member of this family, whom I saw repeatedly in attacks, the swellings
came on in different parts.; for example, the under lip would be swollen to such
a degree that the mouth could not be opened. The hands enlarge suddenly,
so that the fingers can not be bent. The attacks recur every three or four
weeks. Accompanying them are usually gastro-intestinal attacks, severe colic,
pain, nausea, and sometimes vomiting. It is quite possible that some of the
cases of Leyden's intermittent vomiting may belong to this group. The colic
is of great intensity and usually requires morphia. Arthritis apparently does
1104 DISEASES OF THE NERVOUS SYSTEM.
not occur. Periodic attacks of cardialgia have also been met with during the
outbreak of the oedema. Hemoglobinuria has occurred in several cases.
The disease has affinities with urticaria, the giant form of which is prob-
ably the same disease. There is a form of severe purpura, often with urticarial
manifestations, which is also associated with marked gastro-intestinal crises,
and it is interesting to note that Schlesinger has reported a case in which a
combination of erythromelalgia, Eajmaud's disease, and acute oedema occurred.
Quincke regards the condition as a vaso-motor neurosis, under the influence
of which the permeability of the vessels is suddenly increased. Milroy, of
Omaha, has described cases of hereditary oedema, twenty-two individuals in
six generations, in which there existed from birth a solid oedema of one or of
both legs, without any special inconvenience or any progressive increase of the
disease.
Some years ago I described a remarkable vaso-motor neurosis characterized
by sweUing and tumefaction of the whole arm on exertion. My patient was a
man, healthy in every other respect. A similar case has been observed in
Philadelphia ; on the supposition that it might be due to pressure, the axillary
vessels were exposed, but nothing was found.
The treatment is very unsatisfactory. In the cases associated with anasmia
and general nervousness, tonics, particularly large doses of strychnia, do good.
I have seen great improvement follow the prolonged use of nitroglycerin; and
calcium lactate may be tried, in doses of 15 grains thrice daily.
IV. FACIAL HEMIATROPHY.
A rare affection characterized by progressive wasting of the bones and soft
tissues of one side of the face. The atrophy starts in childhood, but in a few
cases has not come on until adult life. Perhaps after a trifling injury or disease
the process begins, either diffusel}^ or more commonly at one spot on the skin.
It gradually spreads, involving the fat, then the bones, more particularly the
upper jaw, and last and least the muscles. The wasting is sharply limited at
the middle line, and the appearance of the patient is very remarkable, the face
looking as if made up of two halves from different persons. There is usually
change in the color of the skin and the hair falls. Owing to the wasting of
the alveolar processes the teeth become loose and ultimately drop out. The
eye on the affected side is sunken, owing to loss of orbital fat. There is usually
hemiatrophy of the tongue on the same side. Disturbance of sensation and
muscle twitching may precede or accompany the atrophy. In a majority of
the cases the atrophy has been confined to one side of the face, but there are
instances on record in which the disease was bilateral, and a few cases in which
there were areas of atrophy on the back and on the arm of the same side.
Of the autopsies, Mendel's alone is satisfactory. There was the terminal
stage of an interstitial neuritis in all the branches of the trigeminus, from
its origin to the periphery, most marked in the superior maxillary branch.
The disease is recognized at a glance. The facial asymmetry associated
with congenital wrjmeck must not be confounded with progressive facial hemi-
atrophy. Other conditions to be distinguished are : Facial atrophy in anterior
polio-myelitis, and more rare!}' in the hemiplegia of infants and adults; the
atrophy following nuclear lesions and sympathetic nerve paralysis; acquired
VASO-MOTOR AND TROPHIC DISORDERS. 1105
facial hemihypertrophy, such as in the case recorded by D, W. Montgomery,
which may by contrast give to the other side an atrophic appearance; and,
lastly, scleroderma (a closely related affection), if confined to one side of the
face. The precise nature of the disease is still doubtful, but it is a suggestive
fact that in many of the cases the atrophy has followed the acute infections.
It is incurable.
V. ACROMEGALY.
Definition. — A dystrophy characterized by abnormal processes of growth,
chiefly in the bones of the face and extremities.
The term was introduced by Marie, and signifies large extremities.
Etiology. — It occurs rather more frequently in women. The affection usu-
ally begins about the twenty-fifth year, though in some instances as late as the
fortieth. Eheumatism, syphilis, and the specific fevers have preceded the de-
velopment of the disease, but probably have no special connection with it. In
America many cases have now been reported.
Symptoms. — In a well-marked case the disease presents most characteristic
features. The hands and feet are greatly enlarged, but are not deformed, and
can be used freely. The hypertrophy is general, involving all the tissues, and
gives a curious spade-like character to the hands. The lines on the palms are
much deepened. The wrists may be enlarged, but the arms are rarely affected.
The feet are involved like the hands and are uniformly enlarged. The big
toe, however, may be much larger in proportion. The nails are usually broad
and large, but there is no curving, and the terminal phalanges are not bulbous.
The head increases in volume, but not as much in proportion as the face, which
becomes much elongated and enlarged in consequence of the increase in the
size of the superior and inferior maxillary bones. The latter in particular
increases greatly in size, and often projects below the upper jaw. The alveolar
processes are widened and the teeth separated. W. W. Graves has called atten-
tion to the value of this separation of the teeth as an important early sign.
The soft parts also increase in size, and the nostrils are large and broad.
The eyelids are sometimes greatly thickened, and the ears enormously hyper-
trophied. The tongue in some instances becomes greatly enlarged. Late in
the disease the spine may be affected and the back bowed — kyphosis. The bones
of the thorax may slowly and progressively enlarge. With this gradual increase
in size the skin of the hands and face may appear normal. Sometimes it is
slightly altered in color, coarse, or flabby, but it has not the dry, harsh appear-
ance of the skin in myxoedema. The muscles are sometimes wasted. Changes
in the thyroid have been found, but are not constant. The gland has been
normal in some, atrophied in others, and in a third group of cases enlarged.
Erb, who has made an elaborate study of the disease, has noticed an area of
dulness over the manubrium sterni, which he thought possibly due to the per-
sistence or enlargement of the thymus. Headache is not uncommon. Somno-
lence has been noted in many cases. Menstrual disturbance may occur early,
and there may be suppression. Ocular symptoms are common. Hertel has
analyzed 175 recorded cases, 92 of which presented eye complications. In
three-fourths of these the optic nerves were affected — usually atrophy, rarely
neuritis. Bitemporal hemianopia is often an early sign. The disease may
persist for fifteen, twenty, or more years.
1106 DISEASES OF THE NERVOUS SYSTEM.
Pathological Anatomy. — To April, 1902, there were 262 cases on record
with 77 autopsies, in only 4 of which the pituitary gland was not involved
(Woods-Hutchinson). In 24 cases in which it was examined the thyroid was
normal in 5, hypertrophied in 12; the thymus in 17 examined was absent in
7, hypertrophied in 3, and persistent in 7 (Furnival). In Osborne's case the
heart was enormous^ weighing 2 pounds 9 ounces.
Owing to the remarkable changes in the pituitary gland in acromegaly, it
has been suggested that the disease is a nutritional disturbance analogous to
myxcedema, and caused directly by disturbance in the function of this organ.
The evidence from comparative anatomy and embryolog}^ shows that the pitui-
tary body is a very " complex organ, consisting of an anterior secreting glandu-
lar organ; a water-vascular duct; a posterior, sensitive, nervous lobe, of which
the last two — nameh', the duct and the nervous lobe — were morphologically
well developed and functioned in ancestral vertebrates, but have become oblit-
erated and atrophied in structure and function forever above larval acraniates "
(Andriezen, British Medical Journal, 1894, i). The pituitary body continues
active, but the duct is obliterated " and the gland changed into a ductless
gland ; the secretion becomes an ' internal secretion,^ " which is absorbed by the
lymphatics. The extraordinary frequency with which the pituitary is involved
in this disease lends weight to the view that it is, in the words of Woods
Hutchinson, the growth centre, or at any rate the proportion regulator of
the skeleton.
It has been, suggested by Massalongo and others that gigantism and acro-
megaly are one and the same disease, both due to the superfunction of the
pituitary gland. Certain persons exhibited as giants, or who have been " strong
men " and wrestlers, have become acromegalic, and the skulls of some notable
giants show enormous enlargement of the sella turcica.
There is a congenital progressive hypertrophy of one extremity or of a
part of it, or of one side of the body, — the so-called giant growth^ which does
not appear to have any connection with acromegaly.
Treatment. — The treatment does not appear to have any influence upon
the progress of the disease. The th}Toid extract has been tried in many cases,
without, so far as my personal experience goes, any benefit. Extract of the
pituitary gland has also been used. The lung extract has been employed in
some cases of pulmonary osteo-arthropathy. In a case of Caton's, of Liverpool,
an unsuccessful attempt was made to extirpate the pituitary body.
Osteitis Deformaxs {Paget' s Disease).
Definition. — A disease characterized by " enlargement and forward pro-
jection of the head, dorso-cervical kyphosis, prominence of the clavicles, spread-
ing of the base of the thorax, a diamond-shaped abdomen, crossed by a deep
sulcus, a relative increase in the width of the hips, and an outward and forward
bowing of the legs."
It is a rare disease. I have seen only 4 cases — 1 in Philadelphia, which
is figured in Ashhurst's Surgery, and 3 in Baltimore. Of these, one is un-
reported; the others I saw with Watson (who has recorded the case, Johns
Hopkins Hospital Bulletin, 1898) and vdth A. D. xA.tkinson. Careful studies
have been made by J. C. Wilson, by Elting, and by Packard, Steele, and
» VASO'MOTOR AND TROPHIC DISORDERS. 1107
Kirkbride, from whose exhaiistive paper I have taken the definition. About
67 typical cases are on record: 41 males, 24 females, and in 2 the sex was
not given. In 49 cases the bones of the skull were involved, in 47 both tibiae,
in 40 the femur, and in 31 the spine. These figures from Packard's paper
give the relative frequency with which the bones are attacked. The shorten-
ing of the stature is remarkable; in Watson's patient the height at forty-two
was 5 feet llf inches, and at sixty-two it was 5 feet 2^ inches. The head
had increased 3^ inches.
Etiology. — The etiology of the disease is unknown; it is possibly allied to
but not identical with osteo-malacia, fragilitas ossium, and acromegaly. There
is a curious relationship between osteitis deformans and malignant tumors,
of which a certain number of the patients have died.
The bone structure shows a mixture of rarefying osteitis, with large and
irregular Haversian canals, and of a formative osteitis, with certain Haversian
canals narrowed and lamellge of recent formation.
Diagnosis. — The diagnosis is readily made. The features given in the defi-
nition make up a most typical picture. As Marie states, in Paget's disease the
face is triangular with the base upward ; in acromegaly it is ovoid or egg-shaped
with the large end downward ; while in myxoedema it is round and full -moon-
shaped. Treatment seems to be of no avail.
Hypertrophic Pulmonary Arthropathy.
Marie has given the name hypertrophic pulmonary osteo-arthropathy to a
remarkable disorder, first recognized by Bamberger, characterized by enlarge-
ment of the hands and feet, and of the ends of the long bones, chiefly of the
lower three-fourths of the forearm and legs. Unlike acromegaly, the bones of
the skull and of the face are not involved. The terminal phalanges are much
enlarged and show both transverse and longitudinal curves ; the nails, too, are
large and much curved over the ends of the phalanges. Scoliosis and kyphosis
are rarely seen. The disease is very chronic, and in nearly all cases has been
associated with some long-standing affection of the bronchi, lungs, or pleura
(hence the name pulmonary osteo-arthropathy) , of which sarcoma, chronic
bronchitis, chronic tuberculosis, and empyema have been the most frequent.
There are several instances in which the affection has developed in the subjects
of syphilis. It occurs usually in adults and in the male sex. Thayer has re-
ported 4 cases from my clinic and has collected 55 typical eases from the
literature. Forty-three showed preceding pulmonary affection; of the remain-
in, 3 followed syphilis, 3 heart-disease, 2 chronic diarrhoea, 1 spinal caries,
and 3 unknown causes.
The essential pathology of the disease is very obscure. Marie suggests that
the toxines of the pulmonary disease are absorbed into the circulation and
exercise an irritant action on the bony and articular structures, causing an
ossifying periostitis. Thorburn thinks that it is a chronic tuberculous affec-
tion of a large number of bones and joints of a benign type.
Leontiasis Ossea,
In a remarkable condition known as leontiasis ossea, there is hyperos-
tosis of the bones of the cranium, and sometimes those of the face. The
1108 DISEASES OF THE NERVOUS SYSTEM.
description is largely based upon the skulls in museums, but Allen Starr has
recently reported an instance in a woman, who presented a slowly progressing
increase in the size of the head, face, and neck, the hard and soft tissues both
being affected. He has applied to the condition the term megalo-cephaly.
Putnam states that the disease begins in early life, often as a result of injury.
There may be osteophytic growths from the outer or inner tables, which in the
latter situation may give the symptoms of tumor.
Osteogenesis Imperfecta {Fragilitas Ossium).
This is a systemic disease of the foetus in which the normal osseous develop-
ment does not occur. At birth there is marked fragility of all the bones. There
may have been intra-uterine fractures which have united and show large cal-
luses. The extremities are often bent and deformed. The main features are
defective development of the cranium and fragility of all the bones. It was
thought that death always occurred, but Nathan has shown that some of the
patients survive and that the bones become firmer as the child grows older.
Treatment consists in using every protection against injury. Fractures usually
unite readily.
Achondroplasia (Chondrodystropliia FcetaJis).
Achondroplasic dwarfs are easily recognized. They are well nourished and
strong, and of average intelligence. Their height varies from 3 to 4 feet; the
head and trunk are of about normal size, but the extremities are very short, the
fingers, when the arms are at the sides, reaching little below the crest of
the ilium. The important point in diagnosis is that in the shortness of the
limbs it is the proximal segments which are specially involved, the humerus
and femur being even shorter than the ulna and tibia (rhizomelia) . The limbs
are considerably bent, but this is more an exaggeration of normal curves and
abnormalities in the joints than pathological curves, as in rickets. The features
of rickets are absent. The hand is short, and has a trident shape, since the
fingers, which are of almost equal length, often diverge somewhat. The root
of the nose is depressed, the back flat, and the lumbar lordosis abnormally deep,
owing to a tilting forward of the sacrum. The scapulge are short, the fibulae
longer than the tibise, and the pelvis is contracted ; hence the number of these
cases reported by obstetricians. Heredity plays little part (Marie, Presse
Med., 1900).
Pathologically it is a dystrophy of the epiphysical cartilages. The cartilage
cells are irregularly scattered, and the ground substance is invaded by con-
nective tissue from the periosteum, which seems to send in a band of tissue
across the end of the diaphysis, thus preventing its increase in length, and
causing premature union of epiphysis and diaphysis. The development of the
bones with a membranous matrix seems normal. The etiology of the disease
is unknown. Virchow described it as foetal cretinism, others as foetal rickets
which has run its. course before birth. But it is certainly not always a purely
foetal disease, for it can continue its development during infancy, and we have
had one case under observation which would tend to show that it could even
begin after birth. Most of the cases, however, die either before birth or in
early infancy.
VASO-MOTOR AND TROPHIC DISORDERS. U09
VI. SCLERODERMA.
Definition. — A condition of localized or diffuse induration of the skin.
Lewin and Heller (Die Sclerodermic^ Berlin, 1895) have recently collected
from the literature 508 cases.
Two forms are recognized : the circumscribed, which corresponds to the
keloid of Addison, and to morphoea ; and the diffuse, in which large areas are
involved.
The disease affects females more frequently than males. The cases occur
most commonly at the middle period of life. The sclerema neonatorum is a
different affection, not to be confounded with it. The disease is more common
in the United States than statistics indicate. I have had 20 cases under obser-
vation in the past fifteen years.
In the circumscribed form there are patches, ranging from a few centime-
tres in diameter to the size of the hand or larger, in which the skin has a
waxy or dead-white appearance, and to the touch is brawny, hard, and inelastic.
Sometimes there is a preliminary hypersemia of the skin, and subsequently
there are changes in color, either areas of pigmentation or of complete atrophy
of the pigment — leucoderma. The sensory changes are rarely marked. The
secretion of sweat is diminished or entirely abolished. The disease is more
common in women than in men, and is situated most frequently about the
breasts and neck, sometimes in the course of the nerves. The patches may
develop with great rapidity, and may persist for months or years; sometimes
they disappear in a few weeks.
The diffuse form, though less common, is more serious. It develops first
in the extremities or in the face, and the patient notices that the skin is
unusually hard and firm, or that there is a sense of stiffness or tension in
making accustomed movements. Gradually a diffuse, brawny induration de-
velops and the skin becomes firm and hard, and so united to the subcutaneous
tissues that it can not be picked up or pinched. The skin may look natural,
but more commonly is glossy, drier than normal, and unusually smooth. With
reference to the localization, in 66 observations the disease was universal; in
203, regions of the trunk were affected; in 193, parts of the head or face;
in 287, portions of one or other of the upper extremities; and in 122, portions
of the lower extremities. In 80 cases there were disturbances of sensation.
The disease may gradually extend and involve the skin of an entire limb.
When universal, the face is expressionless, the lips can not be moved, mastica-
tion is hindered, and it may become extremely difiicult to feed the patient.
The hands become fixed and the fingers immobile, on account of the extreme
induration of the skin over the joints. Eemarkable vaso-motor disturbances
are common, as extreme cyanosis of the hands and legs. In one of my cases
tachycardia was present. The disease is chronic, lasting for months or years.
There are instances on record of its persistence for more than twenty years.
Recovery may occur, or the disease may be arrested. One of my patients,
with extensive involvement of the face, ears, and hands, is now, ten years
after the onset, very much better ; the skin of the face is supple and the hands
are much less indurated. The patients are apt to succumb to pulmonary
pomplaints or to nephritis. Rheumatic troubles have been noticed in some
1110 DISEASES OF THE NERVOUS SYSTEM.
instances; in others, endocarditis. Eaynaud's disease may be associated with
it, as in 2 cases described by Stephen Mackenzie. I have seen an instance of
the diffuse form in "which the primary symptoms were those of local asphyxia
of the fingers, and in which, with extensive scleroderma of the arms and
hands and face, there were cyanosis and swelling of the skin of the feet
without any brawny induration. The pigmentation of the skin may be as
deep as in Addison's disease, for which cases have been mistaken ; scleroderma
may occur as a complication of exophthalmic goitre.
The remarkable dystrophy known as sderodactylie belongs to this-disorder.
There are symmetrical involvements of the fingers, which become deformed,
shortened, and atrophied; the skin becomes thickened, of a waxy color, and is
sometimes pigmented. Bulls and ulcerations have been met with in some in-
stances, and a great deformity of the nails. The disease has usually followed
exposure, and the patients are much worse during the winter, and are curiously
sensitive to cold. There may be changes in the skin of the feet, but the de-
formity similar to that which occurs in the hand has not been noted. Some
of the cases present in addition diffuse sclerodermatous changes of the skin
of other parts. In Lewin and Heller's monograph there are 35 cases of isolated
sclerodactylism. and 106 cases in which it was combined with scleroderma.
The patholog}' of the disease is unknown. It is usually regarded as a
tropho-neurosis, probably dependent upon changes in the arteries of the skin
leading to connective-tissue overgrowth. The thyroid has been found atro-
phied.
Treatment. — The patients require to be warmly clad and to be guarded
against exposure, as they are particularly sensitive to changes in the weather.
"Warm baths followed by frictions with oil should be systematically used. I have
tried the th}Toid feeding thoroughly in the diffuse form. In one case the disease
appears to be arrested ; the patient has taken the extract for nearly seven years.
In a second case, after a year the face became softer, and there has been per-
manent improvement. In a case of quite extensive localized scleroderma, the
patches became softer and the pigmentation much less intense. Salol in 15-
grain doses three times a day is stated to have been successful in several cases.
Here a brief reference may be made to the remarkable trophic lesion de-
scribed by Da Silva Lima, which is met with in negroes in Brazil, Africa, India,
and occasionally in the Southern States. It is confined to the toes, usually the
little toe, and begins as a furrow on the line of the digito-plantar fold. This
gradually deepens, the end of the toe enlarges, and, usually without inflam-
mation or pain, the toe falls off. The process may last some years. Cases have
been reported in America by Hornaday, Pittman, F. J. Shepherd, and Mor-
rison.
SECTION XL
DISEASES OF THE MUSCLES.
I. MYOSITIS.
Definition. — Inflammation of the voluntary muscles.
A primary myositis occurs as an acute, subacute, or chronic affection. It is
seen in two forms — the suppurative and non-suppurative. The former variety,
known as infectious myositis, is especially frequent in Japan, where, according
to Miyake, some 250 cases have been reported; but he claims that some of these
examples belong to other affections. Miyake personally saw 33 cases in Japan
during twenty-one months' practice, and took cultures from all but one of
them. In 2 cases the results were negative, but in 27 a pure culture of the
staphylococcus pyogenes aureus was obtained, while in another the streptococ-
cus and in 2 more the albus with the aureus was grown. The malady may
involve one or many muscles, and is usually sudden in its onset. There is also
high fever and marked prostration. Subsequently abscesses occur in the in-
durated muscles, and pysemia may ensue if the implicated muscles are not
thoroughly evacuated. Of the second form a number of characteristic cases
have been described of late years under the term dermato-myositis. There have
been two examples of this disease at the Johns Hopkins Hospital, The muscle
inflammation is here multiple, and is associated with oedema and a dermatitis.
The case of E. Wagner may be taken as a typical example, A tuberculous but
well-built woman entered the hospital, complaining of stiffness in the shoul-
ders and a slight oedema of the back of the hands and forearms. There was
paresthesia, the arms became swollen, the skin tense, and the muscles felt
doughy. Gradually the thighs became affected. The disease lasted about three
months. The post mortem showed slight pulmonary tuberculosis; all the
muscles except the glutei, the calf, and abdominal muscles were stiff and firm,
but fragile, and there were serous infiltration, great proliferation of the inter-
stitial tissue, and fatty degeneration. Similar cases have been reported by
Unverricht, Hepp, Jacoby, of New York, and others. In the case reported
by Jacoby the muscles were firm, hard, and tender, and there was slight oedema
of the skin. The cases usually last from one to three months, though there
are instances in which it has been longer. The swelling and tenderness of the
muscles, the oedema, and the pain naturally suggest trichinosis, and indeed
Hepp speaks of it as a pseudo-trichinosis. The nature of the disease is un-
known. One of Senator's cases presented marked disorders of sensation and
has been named neuro-myositis. Wagner suggests that some of these cases
were examples of acute progressive muscular atrophy. The differentiation
1111
1112 DISEASES OF THE MUSCLES.
from trichinosis is possible only by removing a portion of the mnscle. It
has not yet been determined whether the eosinophilia descril^ed by Brown is
peculiar to the trichinosis myositis. Still another variety has been described
which differs from dermato-myositis chiefly in the presence of a greater or less
amount of interstitial hsemorrhages between the muscle fibres and in the pres-
ence of circulatory s}Tnptoms caused by the implication of the cardiac muscle.
It is known as pol3Tiiyositis hsemorrhagica. About 12 cases have been reported.
Myositis Ossificans Progeessiva.
In this rare and remarkable affection the process begins in the neck or
back, usually with swelling of the affected muscles, redness of the skin, and
slight fever, or with small nodules in the muscles which appear and disap-
pear. After subsiding an induration remains, which becomes progressively
harder as the transformation into bone takes place. The disease may ulti-
mately involve a majority of the skeletal muscles. ISTothing is known of the
etiology. Malformations, particularly of the thumbs and big toes, are common.
II. MYOTONIA (Thomsen's Disease).
Definition. — An infection characterized by tonic cramp of the muscles on
attempting voluntary movements. The disease received its name from the
physician who first described it, in whose family it has existed for five gen-
erations.
While the disease is in a majority of cases hereditar}^, hence the name myo-
tonia congenita, there are other forms of spasm very similar which may be
acquired, and others still which are quite transitory.
Etiology. — All the tyiDical cases have occurred in family groups; a few
isolated instances have been described in which similar symptoms have been
present. Males are much more frequently affected than females. In 102 re-
corded cases, 91 were males and only 11 females (Hans Koch). The disease
is rare in America and in England; it seems more common in Germany and
in Scandinavia.
Symptoms. — The disease comes on in childhood. It is noticed that on
account of the stiffness the children are not able to take part in ordinary
games. The peculiarity is noticed only during voluntary movements. The
contraction which the patient wills is slowl}^ accomplished; the relaxation
which the patient wills is also slow. The contraction often persists for a little
time after he has dropped an object which he has picked up. In walking, the
start is ditficult; one leg is put forward slowly, it halts from stiffness for a
second or two, and then after a few steps the legs become limber and he walks
without any difficult}'. The muscles of the arms and legs are those usually
implicated; rarely the facial, ocular, or larjmgeal muscles. Emotion and cold
aggravate the condition. In some instances there is mental weakness. The
sensation and the reflexes are normal. G. M. Hammond has reported three
remarkable cases in one family, in which the disease began at the eighth year
and was confined entirely to the arms. It was accompanied with some slight
mental feebleness. The condition of the muscles is interesting. The patients
appear and are muscular, and there is sometimes a definite hypertrophy of the
PARAMYOCLONUS MULTIPLEX. 1113
muscles. The force is scarcely proportionate to the size. Erb has described
a characteristic reaction of the nerve and muscle to the electrical currents — ■
the so-called myotonic reaction, the chief feature of which is that normally
the contractions caused by either current attain their maximum slowly and
relax slowly, and vermicular, wave-like contractions pass from the cathode to
the anode.
The disease is incurable, but it may be arrested temporarily. The nature
of the affection is unknown. In the only autopsy made Dejerine and Sottas
have found hypertrophy of the primitive fibres with multiplication of the
nuclei of all the muscles, including the diaphragm, but not the heart. The
spinal cord and the nerves were intact. From Jacoby's latest studies it is
doubtful whether these changes in the muscles are in any way characteristic
or peculiar to the disease. J. Koch, however, has found, in addition to the
muscle hypertrophy, degenerative and regenerative changes present, which he
considers sufficient to account for the myotonic disorder. Karpinsky and von
Bechterew, from careful urinary examinations, regard the affection as due to
an auto-intoxication of the muscle tissue, caused by some faulty metabolism.
No treatment for the condition is known.
III. PARAMYOCLONUS MULTIPLEX (Myoclonia).
An affection, described by Friedreich, characterized by clonic contractions,
chiefly of the muscles of the extremities, occurring either constantly or in
paroxysms.
The cases have been chiefly in males, and the disease has followed emo-
tional disturbance, fright, or straining. The contractions are usually bilateral
and may vary from fifty to one hundred and fifty in the minute. Occasionally
tonic spasms occur. They are not accompanied by any sensory disturbances.
In the intervals between the attacks there may be tremors of the muscles. In
the severe spasms the movements may be very violent ; the body is tossed about,
and it is sometimes difficult to keep the patient in bed. Gucci has described
a family in which the affection has occurred in three generations.
Weiss has also noted heredity in four generations. According to this
author the essential symptoms are continuous or paroxysmal contractions,
usually symmetrical and rhythmical, of muscles otherwise normal, which cease
during sleep. There are neither psychical nor sensory disturbances. The con-
dition is most common in young males, and is unaffected by treatment. Ray-
mond groups this disease with fibrillary tremors, electric chorea (Henoch), tic
non douloureux of the face, and the convulsive tic, under the name of myo-
clonies, believing that it is only one link in a chain of pathological manifesta-
tions in the degenerate. Dana, in 1903, divided the myoclonias into five
groups. In the first he placed paramyoclonus multiplex, and considered the
names of four somewhat similar affections as synonyms of the same.
IV. MYASTHENIA GRAVIS.
(Asthenic Bulbar Paralysis; Erb-G-oldflam's Symptom-Complex.)
Some sixty cases have been analyzed by Harry Campbell and Edwin Bram-
well (Brain, 1900). The etiology is unknown. Young persons are chiefly
1114 DISEASES OF THE MUSCLES.
affected. The muscles iuneryated by the bulb are first affected — those of the
ej'es, the face, of mastication, and of the neck. All the voluntary muscles
may become involved. After rest the power is recovered. In severe cases
paralysis may persist. The myasthenic reaction of Jolly is the rapid exhaus-
tion of the muscles, by faradism, not by galvanism. There are marked remis-
sions and fluctuations in the severity of the symptoms.
Examination of the nervous system has revealed no abnormality. Weigert
found a thymus tumor with metastatic growths in the muscles. Hun, Bloomer,
and Streeter have described an infiltration of the muscles and of the th}Tnus
gland with h-mphoid cells and a proliferation of the glandular elements of the
th}Tnus. More recently E. Link has recorded similar findings.
The diagnosis is easy — from the ptosis, the facial expression, the nasal
speech, the rapid fatigue of the muscles, the myasthenic reaction, the absence
of atrophy, tremors, etc., and the remarkable variations in the intensity of
the symptoms. Of the 60 cases, 23 ended fatally. The patient may live many
years; recovery may take place. Eest, strychnia in full doses, massage alter-
nate courses of iodide of potassium and mercury may be tried.
V. AMYOTONIA CONGENITA.
( Oppenlieimfs ^Disease. )
A congenital affection characterized by general or local hypotonus of the
voluntary muscles Oppenheim called the disease myotonia, but this is pho-
netically so similar to myotonia (Thomsen's disease) that the name amyotonia
of English writers is preferable.
Collier and Wilson (Brain, 1908), who have analyzed the recorded cases,
give the following definition : " A condition of extreme flaccidity of the mus-
cles, associated with an entire loss of the deep reflexes, most marked at the
time of birth and always showing a tendency to slow and progressive amelio-
ration. There is great weakness but no absolute paralysis of any of the mus-
cles. The limbs are most affected; the face is almost always exempt. The
muscles are small and soft, but there is no local wasting. Contractures are
prone to occur in the course of time. The faradic excitability in the muscles
is lowered and strong faradic stimuli are borne without complaint. ISTo other
s}Tnptoms indicative of lesions of the nervous system occur."
In Spiller's case no lesions were found, but in an autopsy by Baudouin
the cells of the anterior horns were found to be small, and there were extensive
changes in the muscle fibres, similar to those in the myopathies.
INDEX
Abasia, 1090, 1099.
Abdominal typhus, 57.
Abducens nerve (see Sixth Nerve), 1015.
Aberrant thyroid glands, 764.
Abortion, in relapsing fever. 111; in smallpox, 120;
in syphilis, 278.
Abscess, atheromatous, 849; of brain, 993; in
appendicitis, 516; in glanders, 264; of kidney
(pyonephrosis), 703; hepato-pulmonary, in
amoebic dysentery, 5; of liver, 4, 563; of lung,
640; of mediastinum, 662; of parotid gland, 441;
of tonsils, 446; perinephric, 717; cerebral, 993;
pyseraic, 216; retro-pharyngeal, 444; tropical, 4,
563.
Acanthocephala, 51.
Acardia, 843.
Acarus scabiei, A. folliculorum, 52.
Accentuated aortic second sound, in chronic
Bright's disease, 698; in arterio-sclerosis, 852.
Accessory spasm, 1030.
Acephalocysts (see Hydatid Cysts).
Acetonsemia, 418.
Acetone, 416; tests for, 416.
Acetonuria, 682.
Achondroplasia, 769, 1108.
Achromotopsia in hysteria, 1081.
Achylia gastrica, 493.
Acne, from bromide of potassium, 1065;rosacea, 371.
Acromegaly, 1105; and gigantism, 1106.
Actinomycosis, 263; pulmonary, 264; cutaneous,
265; cerebral, 265; digestive, 264.
Acute bulbar paralysis, 905.
Acute yellow atrophy, 538.
Addison's disease, 756; asthenia in, 758; pigmenta-
tion of skin in, 757.
Addison's pill, 281; keloid, 1109.
Adenie, 739.
Adenitis, in scarlet fever, 136 ; tuberculous, 306.
Adenoid growths in pharynx, 447.
Adherent pericardium, 782.
Adhesive pylephlebitis, 542.
Adiposis dolorosa, 432.
Adrenalitis, acute heemorrhagic, 760.
Adrenal insufficiency, 760.
Adrenals, in Addison's disease, 757.
Aegophony, 177, 647.
Aerophagia, 490.
Aestivo-autumnal fever, 20.
Afferent system, diseases of, 886.
Ageusia, 1026.
Agoraphobia, 1089.
Agraphia, 959.
Ague, 10; cake (see Enlakged Spleen), 23.
Ainhum, 1110.
"Air-hunger" in diabetes, 417.
Akinesia algera, 1090.
Akoria, 495.
Albini, nodules of, 844.
Albinism, in leprosy (lepra alba), 362; of the lung,
635.
Albumin, tests for, 673.
Albuminous expectoration in pleurisy, 654.
Albuminuria, 672; of adolescence, 672; in ap-
pendicitis, 515; and Ufe assurance, 675; cyclic,
672; dietetic, 673; febrile, 673; functional, 672;
in acute Bright's disease, 688; in chronic Bright's
disease, 693, 698; in diabetes, 416; in diphtheria,
204; in epilepsy, 1062; in erysipelas, 212; in
gout, 405; intermittent, 673; in malarial fever,
16; in pneumonia, 179; in scarlet fever, 134; in
typhoid fever, 88; in variola, 119; neurotic, 673;
orthostatic, 672; paroxysmal, 673; physiological,
672; prognosis in, 675; in yellow fever, 237.
Albuminuric retinitis, 1007.
Albuminuric ulceration of the bowels, 502.
Albumosuria, 674; myelopathic, 674.
Alkaptonuria, 681; and ochronosis, 681.
Alcohol, effects of, on the digestive system, 370;
on the kidneys, 371; on the nervous system, 370;
poisonous effects of, 370.
Alcoholic neuritis, 1001.
Alcohohsm, 369; acute, 369; and tuberculosis, 371;
chronic, 369.
Aleppo button, 9.
Alexia, 959.
Algid form of malaria, 22.
Allantiasis, 381.
AUocheiria, 891.
Alopecia, in syphilis, 268.
Alternating paralysis (see Crossed Paralysis).
Altitude, effects of high, 366.
Altitude in tuberculosis, 285, 355.
Amaurosis, hysterical, 1008, 1081; toxic, 1008;
uraemic, 684, 699; in haematemesis, 489.
Amblyopia, 1008; tobacco, 1008; crossed, 1011.
Ambulatory typhoid fever. 71, 91.
Amoeba, dysenteriae, 2; in Uver abscess, 2, 563; in
sputa, 6.
Amoebic dysentery, 2.
AmmoniEemia, 706.
Amnesia verbalis, 959.
Amphistome, 27.
Amphoric, breathing, 331, 659; echo, 331.
Amyloid disease, in phthisis, 321; in syphilis, 269;
of kidney, 702; of liver, 571.
Amyosthenia, 1089.
Amyotonia, 1114.
Amyotrophic lateral sclerosis, 901.
1115
1116
INDEX.
Anaemia, 718; aialastic, 726; bothriocephalus, 30;
in ankj'lostomiasis, 46; from Bilharzia, 27 ; of the
brain, 964; in chlorosis, 722; from gastric atrophy,
462; from hsemorrhage, 719; miner's, 44; brick-
maker's, 44; tunnel, 44; from inanition, 721;
from lead, 376; idiopathic, 724; in gastric cancer,
482; in gastric iilcer, 475; general, 719; local,
718; in Hodgkin's disease, 741 ; Ij-mphatica, 739;
mountain, 366; in malarial fever, 23; in rheuma-
tism, 222; in sj-philis, 268; in tj'phoid fever, 76;
primary or essential, 721 ; progressive pernicious,
724; pseudo, 718; secondary' or sj-mptomatic,
719; of spinal cord, 934; splenic, 762; toxic, 721.
Angemic murmurs (see H.EM1C Murmurs).
Anaemic necrosis, 823.
Anaesthesia, dolorosa, 939; in haematomyelia, 936;
in hemiplegia, 973; in hysteria, 1080; in leprosy,
362; in locomotor ataxia, 891; in Mor\-an's disease,
944; paralj'sis, 1003; pneumonia, 185; inrailway
spine, 1097; in unilateral lesions of the cord, 933.
Analgesia in hysteria, 1080; in Mor%-an's disease,
944; in sjTingo-myelia, 943.
Anarthria, 956.
Anasarca (see Dropsy).
Anchmeromj-ia luteola, 56.
Aneurism, 853; arterio-venous, 854, 865; cirsoid,
853; cylindrical, 853; dissecting, 854; embolic,
854; false, 854; fusiform, 853; mycotic, 854; of
the abdominal aorta, 863; of the branches of the
abdominal aorta, 865; of the cerebral arteries,
982; of thecoeliacaxis, 865; of heart, 830; of the
hepatic artery, 865; of the renal artery, 865; of
the splenic artery, 865 ; of the superior mesenteric
artery, 865; traction, 855; true, 853; varicose,
865.
Aneurism, of thoracic aorta, 855; haemorrhage in,
859; pain in, 858; TufneU's treatment of, 861;
unilateral sweating in, 860.
Aneurism, verminous, in the horse, 45, 855.
Aneurismal varix, 865.
Angina, crural, 853; Ludovici. 444; simplex, 442;
suffocativa, 193; Vincent's, 201.
Angina pectoris, 839; functional, 841; toxic, 842;
vaso-motor, 842.
Angiocholitis, chronic catarrhal, 544; suppurative
and ulcerative, 544
Angio-neurotic cedema, 1103
Angio-sclerosis, 851.
Anguillula aceti, 51; A. stercoraUs, A. intestinalis,
51.
Animal lymph, 127.
Anisocoria, 1014.
Ankle clonus, in hysterical paraplegia, 914, 1079;
in spastic paraplegia, 909; spurious, 1079.
Ankylostoma duodenale, 45.
Ankylostomiasis, 44.
Anorexia ner^-osa, 495, 1082.
Anosmia, 1006.
Anterior cerebral artery embolism of, 980.
Anterior crural nerve, paralysis of, 1038.
Anthomjda canicularis, 55.
Anthracosis, of lungs, 631; of liver, 556; and
tuberculosis, 632.
Anthrax, 252; bacillus, 252; in animals, 252; ex-
ternal, 253; internal, 254; in man, 253.
Anthropophobia, 1089.
Antipneumococcic serum, 191.
Antitoxin of diphtheria, 195, 209; of pneumonia,
191; of tetanus, 261.
Antityphoid serum, 102.
Anuria, 668; complete, from stone, 668; hysterical,
668.
Anus, imperforate, 521.
Aorta, aneurism, of, 855; double, 854; dynamic
pulsation of, 860; throbbing, 864, 1090; tuber-
culosis of, 349.
Aortic incompetency, 796; sudden death in, 800.
Aortic orifice, congenital lesions of, 845.
Aortic stenosis, 802.
Aortic valves, bicuspid condition of, 844; in-
sufficiency of. 796.
Apex pneumonia, 182.
Aphasia, 955; auditorj' 958; hereditary, 960; in
infantile hemiplegia, 986; medico-legal aspects
of, 960; motor, 960; in phthisis. 334; prognosis
of, 961; sensory, 958; subcortical-motor, 960
subcortical sensory, 959; in tj^phoid fever, 86
tests for, 960; transient, in migraine, 1067
visual, 959.
Aphemia. 956.
Aphonia, hysterical, 1081; in acute larjmgitis, 597;
in adductor paralysis, 1028; in pericardial
effusion, 779.
Aphthae (see Stomatitis, Aphthous) , 434.
Aphthous fever, 367.
Apoplectic habitus, 966; stroke, 969.
Apoplexj-, capillary, 978; cerebral, 966; ingraves-
cent, 970; meningeal, 935; spinal, 936; pul-
monarj', 618.
Appendicitis, 512; acute catarrhal, 513; chronic,
513; obliterative, 513; gangrenous, 513; puru-
lent, 513; relapsing, 516.
Appendicular coUc, 514.
Appendix vermiformis, perforation of, in tji^hoid
fever, 67; faecal concretions in, 513; foreign
bodies in, 513.
Apraxia, 959.
Aprosexia, 447, 450.
Arachnida, parasitic, 52.
Arachnitis (see Meningitis), 925.
Aran-Duchenne type of muscular atrophy, 901,
914; in lead-poisoning, 377.
Arch of aorta, aneurism of, 855.
Arcus senilis, 827.
Argas moubata, 53.
Argyll Robertson pupU, 1014; in ataxia, 889; in
general paralj-sis, 897.
Arithmomania, 1054.
Arm, peripheral paralysis of (see Paralysis of
Brachial Plexus).
Arrhythmia. 833.
Arsenical neuritis, 380, 1002.
Arsenical pigmentation, 380; in chorea, 1050.
Arsenical poisoning, 379; paralysis in, 380.
Arteries, diseases of, 847; calcification of, 847;
degeneration of, 847; tuberculosis of, 349.
Arterio-capiUary fibrosis, 847.
Arterio-sclerosis, 847; diffuse, 850; in lead-poison-
ing, 378; in migraine, 1067; nodular form, 849;
in phthisis, 337; senile form, 850.
Arterio-venous aneurism, 865.
Arteritis in tjiahoid fever, 69, 78; syphilitic, 277.
Arthralgia from lead, 378.
Arthri tides, post-febrile, 217; in gout, 404.
INDEX.
1117
Arthritis, acute, in infants, 226; gonorrhcEal, 282;
in acute myelitis, 945; in cerebro-spinal meningitis,
162; in chorea, 1045; in dengue, 156; in dysentery,
245; in haemophilia, 749; in Malta fever, 248; in
small -pox, 120; in tabes dorsalis, 892; multiple sec-
ondary, 225; in purpura, 744; rheumatoid, 389; in
scarlet fever, 135; septic, 225; in typhoid fever, 89.
Arthritis deformans, 389; acute, 226; as a chronic
infection, 390; in children, 393; general progres-
sive form, 391; Heherden's nodes in, 391; relation
of, to diseases of nervous system, 389; partial or
mono-articular form, 392; vertebral form, 392.
Arthropathies in tabes, 892.
Arthropathy, hypertrophic pulmonary, 1107.
Ascariasis, 38.
Ascaris lumbricoides, 38.
Ascites, 589, 592; from cancerous peritonitis, 588;
from cirrhosis of the liver, 559; from syphiHs of
the liver, 275; in cancer of the liver, 569; in
tuberculous peritonitis, 311; physical signs of,
589; treatment of, 592.
Ascitic fluid, chylous, 590; serous, 590; heem-
orrhagic, 590.
Aspergillus, in lung, 324; fumigatus, 614.
Asphyxia, local, 1100; death by, in phthisis, 338;
traumatic, 662.
Aspiration, Bowditch's conclusions on, 653; in
empyema, 654; in pericardial eiiusion, 782; in
pleuritic effusion, 653.
Aspiration pneumonia, 621.
Astasia-abasia, 1090, 1099.
Asthenic bulbar paralysis, 1113.
Asthenopia, nervous, 1089.
Asthma, bronchial, 609; nasal affections in, 610;
sputum in, 611; cardiac, 609; hay, 594; Leyden's
crystals in, 611, 613; renal, 609, 684; thymic,
599, 772.
Astrophobia, 1089.
Atavism, in haemophilia, 748; in gout, 397.
Ataxia, cerebellar, 954; cerebellar-heredo, 922;
in diabetes, 418; hereditary, 921; in progressive
paresis, 898; locomotor, 886; after small-pox, 120.
Ataxic gait, 890; paraplegia, 920.
Ataxie variolique, 120.
Atelectasis, pulmonary, 622.
Ateliosis, 774.
Atheroma (see Arterio-sclerosis and Phlbbo-
SCLEROSIS).
Atheromatous abscess, 849.
Athetosis, 987; bilateral or double, 911; hysterical,
1080.
Athlete's heart, 797.
Athyrea, 765, 768.
Atmospheric pressure, effects of, 937.
Atremia, 1090.
Atrophy, acute yellow, of liver, 538; of brain, dif-
fuse in general paresis, 896; of brain, unilateral,
986; of muscles, various forms of, 907; progressive
muscular, of central origin, 901; unilateral, of
face, 1104; progressive neural, 905.
Attitude, inpseudo-hypertrophic muscular paralysis,
906; in paralysis agitans, 1043.
Auditory centre, affections of, 1023 ; nerve, diseases
of, 1023; vertigo, 1024.
Aura, forms of, in epilepsy, 1060.
Auto-infection in tuberculosis, 297.
Automatism, in -petit mal, 1062.
Autumnal, catarrh, 594; fever, 59.
Avian tuberculosis, 284.
Axones (axis-cylinder processes), 867.
Babinski syndrome, 860.
Baccelli's sign, 647, 649.
Bacillary dysentery, 242.
Bacilluria in typhoid fever, 88.
Bacillus of Achalme, 221; B. anthracis, 252; B.
botulinus, 381 ; of cholera, 228; B. coli communis
— distinction from typhoid bacillus, 60; in bile-
passages, 545; in faeces of sucklings, 505; in fat
necrosis with colitis, 576; in peritonitis, 581; B.
diphtheriae, 194, 445; B. dysenteriae, 243; B. ente-
ritidis, 381; B. Flexner-Harris, 243; B. gas (B.
aerogenes capsulatus) , in peritonitis, 581 ; in pneu-
mothorax, 658; in pneumaturia, 682 ; in pneumo-
pericardium, 785; B. Klebs-Loeffler, 194; toxin of
195; B. of glanders, 261 ; B. of influenza, 153, 216;
B. in whooping-cough, 149; B. of leprosy, 360; B.
of plague, 239; B. of tetanus, 259; B. pyocyaneus
215, 216; B. leprae, 360; B. mallei, 261; B. pestis,
239; pneumoniae, 168, 623; B. Shiga, 243; B.
tuberculosis, 285, 644; diagnostic value of, 335;
distribution of, 286; in sputum, 323; methods of
detection, 323; outside the body, 286; modes of
growth of, 286; B. typhosus, 59; B. xerosis, 196;
B. "Y," 244.
"Back-stroke" of heart, 795.
Bacteraemia, 214.
Bacteria, proteus group in diarrhoea, 505.
Bacterium, coli commune (see Bacillus Con
Communis) ; B. solaniferum, 384.
Balanitis in diabetes, 417.
Balantidium coli, 26.
Ball-thrombus in left auricle, 809.
Ball-valve stone in common duct, 553.
Balne's cough, 449.
Balz's disease, 440.
Banting's method in obesity, 432.
Banti's disease, 762.
"Barben cholera," 383.
Barking cough of puberty, 1081.
Barlow's disease, 753.
Barrel-shaped chest in emphysema, 636; in en-
larged tonsils, 449.
Basedow's disease, 765.
Basilar artery, embolism and thrombosis of, 979.
Baths, cold, in typhoid fever, 100; in hyperpyrexia
of rheumatism, 227 ; in scarlet fever, 139.
Batophobia, 1089.
Beaded ribs in rickets, 428.
Beaumfe's law, 266.
Bed-bug, 54.
Bednar's aphthae, 436.
Bed-sores, acute, in myelitis, 945, 946; in typhoid
fever, 75.
Bell's mania, 1041; palsy, 1019.
Bence-Jones body in albumosuria, 674.
Beri-beri, 249; forms of, 251.
Besoin de respirer, 367.
Bicuspid condition of heart valves, 844.
"Big-jaw" in cattle, 263.
Bile coloring matter, tests for, 535.
Bile-ducts, acute catarrh of, 542; ascarides in, 547;
cancer of, 546; congenital obliteration of, 548;
stenosis of, 547.
1118
INDEX.
Bile-passages, diseases of, 542.
Bilharziosis, 27.
Biliary, cirrhosis of liver, 556; colic, 550; fistnlse,
554.
Bilious remittent fever, 20.
Birth palsies, 910.
Black death, 239.
Black spit of miners, 633.
Black vomit, 237; in dengue, 157.
Black-water fever, 22.
Bladder, paralysis of, in locomotor ataxia, S89;
care of, in myelitis, 947; hjT>ertrophy of, in
diabetes insipidus, 424; tuberculosis of, 347.
Blastomycosis, systemic, 2.
"Bleeders," 747.
Blepharospasm, 1022.
Blindness (see Amaurosis).
Blood and ductless glands, diseases of, 718.
Blood, characters of, in anEemia, 719; in cancer of
the stomach, 482; in chlorosis, 722; in cholera, 230;
in diabetes, 412, 416; in gout, 400; in hcemophiUa,
748; in lead-poisoning, 376; in leuksemia, 735; in
pernicious anaemia, 727; in pneumonia, 177; in
pseudo-leuksemia, Hodgkin's disease, 741; in pur-
pura, 743; in secondary anaemia, 719; in syphilis,
268; in trichiniasis, 42; in tjijhoid fever, 76.
Blood crises, 728.
Blood-letting, in arterio-sclerosis, 853; in cerebral
hsemorrhage, 980; in emphysema, 638; in heart-
disease, 817; in pneumonia, 190; in sun-stroke,
388; in yellow fever, 239.
Blood pressure, in arterio-sclerosis, 851; in pneu-
monia, 177; in typhoid fever, 77.
Blood-serum therapy in diphtheria, 209; in pneu-
monia, 191, in tetanus, 261; in typhoid fever, 102.
Blood-vessels of Uver, affections of, 540.
" Blue disease," 845.
Blue line on gums in lead-poisoning, 376-
Boils, in diabetes, 417; after typhoid fever, 7G;
after small-pox, 120.
Bones, lesions of, in acromegaly, 1105; in congenital
syphilis, 271; fragUity of, in osteogenesis imper-
fecta, 1108; fragihty of, in rickets, 427; in typhoid
fever 88.
Borborygmi, 490, 499.
Bothriocephalus latus, 29; anaemia, 30.
BotuUsm, 381.
BotjToid hver in sj-philis, 275.
Bovine tuberculosis, 284.
Bowel, affections of (see Intestines); acute ob-
struction of, 519; infarction of, 533.
^-oxy-butyric acid, 418, 682.
Brachial plexus, affections of, 1035.
Bradycardia (Brachycardia), 836; paroxysmal, 834;
in tjTDhoid fever, 76.
Brad>T3ncea, 1081.
Brain, diffuse and focal diseases of, 947; abscess of,
993; abscess of. in congenital heart-disease, 846;
affections of blood-vessels of, 961; anaemia of,
964; atrophy and scleroses of, 928; congestion of,
964; cysts in, 989; echinococcus of, 37; haemor-
rhage into, 966; syphilis of, 271, 988; glioma of
988; hj-peraemia of, 964; inflammation of, 992;
oedema of 965; porencephalus of, 986.
Brain-murmur in rickets, 429.
Brain, sclerosis of, 928; diffuse, 929; insular, 930;
miliary, 929; tuberous, 930,
Brain, softening of, red, yellow, and white, 978.
Brain, tubercle of, 342, 988.
Brain, tumors of, 988; medical treatment of, 992;
surgical treatment of, 992; symptoms, general
and locahzing, 989.
Brand's method in typhoid fever, 100.
Breakbone fever (see Dengue), 156.
Breast, funnel, 449; pigeon or chicken, 449.
Breast-pang, 839.
Breath, odor of, in diabetic coma, 418; foul, in
scurvy, 751; in fetor oris, 439; foetid, in enlarged
tonsils, 450.
Breathing (see Respiration); mouth, 447.
Bremer's blood test in diabetes, 419.
Brick-dust deposit in urine, 677.
Brick-maker's anaemia, 44.
Bright's disease, acute. 686; interstitial form of, 688.
Bright's disease, chronic, 692; interstitial form of,
694; causes of, 694; cardio-vascular changes in,
698; hereditary influences in, 694; Edebohls's
operation in, 702; parenchymatous form of, 692.
Briquet, syndrome of, 1081.
Broadbent's sign, 783.
Broca's convolution, lesions of, 960.
"Broken-winded," 821.
Bromism, 1065.
Bronchi, casts of, 613; diseases of, 602; syphilis of,
273.
Bronchial asthma, 609.
Bronchial catarrh (bronchitis), 602.
Bronchial glands, tuberculosis of, 307; enlargement
in whooping-cough, 150, 660; suppuration in, 660.
Bronchiectasis, 606; abscess of brain in, 608;
congenital, 607; cylindrical, 607; rheumatoid
aS'ections in, 608; saccular, 607; sputum in, 608;
universahs, 607.
Bronchiolectasis; 607.
Bronchiolitis exudativa, 609,
Bronchitis, 602; acute, 602; capUlary, 620; chronic,
604; croupous, 613; fibrinous, 613; in measles, 143;
in smaU-pox, 119; in typhoid fever, 84; plastic,
613; putrid, 605.
Bronchocele (see Goitre) 763.
Bronchophony, in pneumonia, 177,
Broncho-pneumonia, 620; acute, 621; chronic, 828;
secondary, 621; acute tuberculous, 315.
Bronchorrhagia, 617.
Bronchorrhoea, 605; serous, 605.
Bronze-sldn in phthiriasis, 54; in Addison's disease,
757; in Basedow's disease, 767; in diabetes, 417;
in Hodgkin's disease, 741.
Brauer's operation, 784.
Brown atrophy of heart, 826.
Brown induration of lung, 615.
Brown-Siquard's paralysis, 933.
Bruit, d'airain, 659; de cuir neuf, 777; de diable,
724,767; de drapeaii, 613; de moulin, 785; depot
fele (see Cracked-pot Sound), 330; de souffle, 789;
oesophageal, 454.
Bubo parotid (see also Parotitis), 441.
Bubonic plague, 240.
Buccal, psoriasis, 439; spots in measles, 142.
Buhl's disease, 747.
Bulbar paralysis, 904; acute, 905; asthenic form,
1113; of cerebral origin, 905; progressive, 901;
pseudo, 905.
Bulimia, 414, 494.
INDEX.
1119
Cachexia, in cancer of the stomach, 482; in Hodg-
kin's disease, 741; malarial, 15, 23; periosteal,
753; saturnine, 376; strumipriva, 770; syphilitic,
268; tropical, 9.
Caisson disease, 937.
Calcareous concretions, in phthisis, 319; in the
tonsils, 450.
Calcareous degeneration, of arteries, 847; of heart,
827.
Calcification, annular, of arteries, 847.
Calcification in tubercle, 296.
Calculi, biliary, 548; "coral," 709; pancreatic, 580;
renal, 709; tonsillar, 450; urinary, 709.
Calculous pyelitis, 704.
Camp fever, 105.
Cancer, of bile-passages, 546, 568; of bowel, 521 ; of
brain, 988; of gall-bladder, 546; green, 738;
of kidney, 714; of liver, 567; of lung, 641; of
oesophagus, 454; of pancreas, 579; of perito-
naeum, miliary, 588; of stomach, 479; acute,
485.
Cancrum oris, 437; in measles, 143.
Canities, the result of neiu-algia, 1069.
Canned goods, poisoning by, 382.
Capillary pulse, in aortic insufficiency, 801 ; in
neurasthenia, 1090; in phthisis, 333.
Capsule, internal, 949; lesions of, 949.
Caput Medusae, 589.
Caput quadratum, in rickets, 429.
Carboluria, 681.
Carbuncle in diabetes, 417.
Carcinoma (see Cancer).
Cardia, spasm of, 491; insufficiency of, 492.
Cardiac disease (see Disease op Heart).
Cardiac murmurs, haemic, in chlorosis, 724; in
chorea, 1049; in idiopathic anaemia, 728.
Cardiac murmurs, organic, in aortic insufficiency,
800; in aortic stenosis, 803; in congenital heart
affections, 846; in mitral incompetency, 807; in
mitral stenosis, 810; in tricuspid valve disease,
812.
Cardiac nerves, neuralgia of, 839.
Cardiac overstrain, 821.
Cardiac septa, anomalies of, 843.
Cardialgia (see Gastralgia).
Cardiocentesis, 832.
Cardio-hepatic angle in pericarditis with effusion,
780.
Cardio-lysis, 784.
Cardio-respiratory murmur, 331.
Cardio-sclerosis, 827.
Cardio-vascular changes in renal disease, 698.
Caries, vertebral, 938.
Carinated abdomen, 303.
Carotid artery, ligature and compression of, in
cerebral haemorrhage, 980.
Carphologia, 85.
Carpo-pedal spasm, 1076.
Carreau, 312.
Carriers, typhoid, 62.
Caseation in tubercle, 296.
Caseous pneumonia, 297, 323.
Casts, blood, of bronchial tubes in haemoptysis,
618; in fibrinous bronchitis, 614; of pelvis of
kidney and ureter, 714.
Casts of urinary tubules, 689; epithelial, 688, 689;
fatty, 693; granular, 693, 698; hyaline, 698.
Casts, tube, in acute Bright's disease, 688; in chronic
Bright's disease, 693, 698.
Catalepsy in hysteria, 1084.
Cataract, diabetic, 419; after typhoid fever, 87.
Catarrh, acute gastric, 456; autumnal, 594; bron-
chial, 602 ; chronic gastric, 459 ; dry, 605; suffoca-
tive, 625.
Catarrhal bronchitis, influence of, in tuberculosis,
294.
Catarrhe sec, 605.
Catarrhus sestivus, 594.
Caterpillar rash, 56.
Cauda equina, lesions of, 940.
Cavernous breathing, 331.
Cavities, pulmonary, 319; physical signs of, 331;
quiescent, 320.
Cayor fly, 56.
Cellulitis of the neck, 444.
Centrum semiovale, lesions of, 949.
Cephalalgia (see Headache).
Cephalic tetanus, 260.
Cephalodynia, 397.
Cercomonas intestinalis, 25; C. hominis, 25.
Cerebellar ataxia, 922, 954; heredo-ataxia, 922;
vertigo, 954.
Cerebellum, tumors, of, 953; affections of, 953.
Cerebral arteries, aneurism of, 982 ; arterio-sclerosis
of, 983; embohsm of, 977; endarteritis of, 983;
syphilitic endarteritis of, 272, 983; thrombosis of,
977.
Cerebral cortex, lesions of, 947.
Cerebral haemorrhage, 966; aneurisms, miliary in,
967; convulsions in, 976; forms of, 968.
" Cerebral pneumonia, " 179.
"Cerebral rheumatism," 224.
Cerebral sinuses, thrombosis of, 983.
Cerebral softening, 977.
Cerebritis (see Encephalitis), 992.
Cerebro-spinal fever, epidemic, 157; anomalous
forms of, 161; complications of, 162; malignant
form, 160; ordinary form, 160.
Cervical pachymeningitis, 924.
Cervical plexus, lesions of, 1033.
Cervical ribs, 1034.
Cervico-brachial neuralgia, 1070.
Cervico-occipital neuralgia, 1033, 1070.
Cestodes, disease due to, 28; visceral, 31.
Chalicosis, 631, 632.
Chancre, 267.
Charbon, 252.
Charcot's joint, 892.
Charcot-Leyden crystals, 499, 611, 732.
Chattering teeth, 1018.
Cheek, gangrene of, 437.
Cheese, poisoning by, 382.
Chest expansion, diminution of, in Graves' disease,
767.
Cheyne-Stokes breathing, Cheyne's original de-
scription of, 827 ; in apoplexy, 970 ; in mj'ocardial
disease, 827; in sun-stroke, 386; in acute miliary
tuberculosis, 299; in uraemia, 684.
Chiasma and tract, affections of, 1009.
Chicken-breast, 428, 449.
Chicken-pox, 128.
Child-crowing, 599, 1056.
Children, constipation in, 527; diabetes in, 417;
diarrhoeal diseases in, 504; tuberculous broncho-
1120
INDEX.
pneumonia in, 315; pneumonia in, 183; tubercu-
losis of mesenteric glands in, 308, 312; mortality
from small-pox in, 120; rheumatism in, 219; ty-
phoid fever in, 91.
Chills (see Rigors), in tjT)hoid fever, 74.
Chloasma phthisicorum, 335.
Chloro-ansemia in phthisis, 333.
Chloroma, 732, 738.
CUorosis, 721 ; and anaemia, sinus thrombosis in,
983; dilatation of stomach in, 723; Egj-ptian, 44;
fever in, 724; heart sjinptoms in, 724; menstrual
disturbance in, 724; rubia, 722; thrombosis in,
724.
Choked disk, 1008.
Cholaemia, 536.
Cholangitis, infective, 553; suppurative, 554, 564;
in tj-phoid fever, 83.
Cholecj'stectomy, 555; indications for, 555.
Cholecystitis acuta, 551.
Cholecystitis, acute infectious, 545; in tj-phoid fever,
83.
Cholecystotomy, 555.
Cholelitliiasis, 548; in tjiihoid fever, 83.
Cholera, asiatica, 228; bacillus of, 228; epidemics
of, 228; infantum, 507; laboratory, 229; nostras,
232; sicca, 231; tj-phoid, 231.
Cholera toxin, 228.
Cholerine, 232.
Cholesteraemia, 536.
Cholesterin in biliary calculi, 550.
Choluria, 535, 682.
Chondrodystrophia foetalis, 769, 1108.
Chorea, acute, 1045; etiologj- of , 1045; heart sjinp-
toms of, 1049; infectious origin of, 1048; in preg-
nancy, 1046; paralysis in, 1049; rheumatism and,
224, 1045; school-made, 1046.
Chorea, canine, 1046; chronic, 1055.
Chorea, habit or spasm, 1047, 1053.
Chorea, Huntingdon's or hereditary, 1055.
Chorea insaniens, 1048, 1050; paralytic form of,
1049; major, 1053; maniacal, 1048; pandemic,
1053; post-hemiplegic, 987; prehemiplegic, 969.
rhjiihmic or hysterical, 1056; senile, 1055; spas-
tica, 911, 1051; Sydenham's, 1045.
Choroid plexuses, sclerosis of, 997.
Choroid, tubercles in, 304.
Choroiditis in sj-philis, 268.
Chovstek's sjTnptom in tetany, 1076.
Chylangiomata, 533.
Chyle vessels, disorders of, 533.
Chylo-pericardium, 784.
Chyluria, non-parasitic, 676; parasitic, 48.
Cicatricial stenosis of bowel, 521.
Ciliary muscle, paralj'sis of, 1014.
Cimex leetularius, 54.
Circulatory system, diseases of, 775.
Circiimcision, inoculation of tuberculosis by, 290;
in hsemophilia, 748.
Circumflex ner\'e, affections of, 1036.
Cirrhosis, of kidney, 694; of liver, 556; of lung, 628;
tuberculous of liver, 342; ventriculi, 461.
Clapotage in dilated stomach, 469.
Claudication, intermittent, 853.
Claustrophobia, 1089.
Cla^-iceps purpurea, poisoning by, 383.
Claims hystericus, 1080.
Claw-hand (main en griff e), 903, 925.
Climate, influence of. in asthma, 612; in chronic
Bright 's disease, 700; in tuberculosis, 354.
Clonus (see Axkle Clonus) ; jaw, 903.
Clownism in hysteria, 1078.
Cnethocampa, 56.
Coal-miner's disease, 631.
Cobalt miners, cancer of lung in, 642.
Coeainization, spinal, in tabes, 895.
Coccidium oviforme, 1.
Coccydj-nia, 1071.
Cochin-China diarrhcea, 51.
Cochlear ner\-e, lesions of, 1023.
Coeliac affection in children, 499.
Cog-wheel respiration, 330.
Coin-sound, 659.
Cold pack, method of giving, 139.
Colic, biliary, 550; in appendicitis, 514; in angio-
neurotic oedema, 1103; Devonshire, 375; in pur-
pura, 745; lead, 377; mucous, 530; renal, 711.
Colica Pictonum, 375.
Colitis, Bilharzial, 28; diphtheritic, 500; entero-,
508; ileo-, 508; mucous, 530; simple ulcerative,
501.
Colles' law, 266.
Colloid cancer, of lung, 641; of peritonaeum, 588;
of stomach, 480.
Colon, cancer of, 521; dilatation of, 531; "giant
growth of," 532; diverticula, 532.
Coloptosis, 529.
Coma, diabetic, 417; epileptic, 1061; from heat-
stroke, 386; from muscular exertion, 686; in acute
encephalitis, 993; in acute yellow atrophy, 539;
in alcoholic poisoning, 369; in apoplexy, 969; in
cerebral sj"philis, 272; in general paresis, 898; in
miiltiple sclerosis, 931; in pernicious malaria, 21;
in rheumatic fever, 224; in thrombosis of cere-
bral sinuses, 984; in tj-phoid fever, 85; urEemic,
684.
Coma vigH, 85.
Comatose form of malaria, 21.
Comma bacillus, 228.
Common bile-duct, obstruction of, 552.
Compensation in valve lesions, 794; disturbance of,
795; loss of, 795.
Composite portraiture in tuberculosis, 293.
Compressed air disease, 937.
Compression and traction of the bowel, 521.
Compression paraplegia, 938.
Concato's disease, 587.
Concretions (see Calcareous).
Concussion of spinal cord, 1097.
Congenital heart affections, 843.
Congenital stenosis of pylorus, 487.
Congenital stricture of the bowel, 521.
Congenital sj-philis, 269.
Conjugate de^^ation in brain tumor, 991; in apo-
plexy, 971 ; in tuberculous meningitis, 303.
Conjunctiva, diphtheria of, 203.
Consecutive nephritis, 703.
Constipation, 525; in adiilts, 525; in infants, 527;
spasmodic, 526; treatment of, 527.
Constitutio Ij-mphatica, 755.
Constitutional diseases, 389.
Consvunption (see Tuberculosis).
Contracted kidneys, 694.
Contracture hysterical, 1079; in hemiplegia, 974;
of nursing women, 1074.
INDEX.
1121
Contusion pneumonia, 166.
Conus arteriosus, stenosis of, 845.
Conus medullaris, lesions oi, 940.
Convalescence, fever of, 72; from typhoid fever,
management of, 104.
Convulsions, epileptic, 1058; hysterical, 1077; in
acute yellow atrophy, 539; in alcoholism, 370;
in aspiration of pleural effusion, 654; in cerebral
haemorrhage, 970 ; in cerebral syphilis, 272, 1060;
in cerebral tumors, 989; in chronic Bright's
disea.se, 693 ; in general paralysis, 897; in hepatic
colic, 551; in infantile hemiplegia, 986; in lead-
poisoning, 378; in meningitis, 926; in rheumatic
fever, 224; in sun-stroke, 386; in typhoid fever,
86; in uriBmia, 684 ; Jacksonian, 1063.
Convulsions, infantile, 1056; relation to rickets, 430.
Convulsive tic, 1053.
Coordination, disturbance of, in tabes, 890.
Copaiba eruption, 144.
Copper test for sugar, 415.
Coprismia, 526, 722.
Coprolalia, 1054.
Coproliths as a cause of appendicitis, 513.
Cor adiposum, 826; biloculare, 843; bovinum, 696,
798; villosum, 776.
Coral calculi, 709.
Coronary arteries, in angina pectoris, 840, 841;
blocking of, in myocardial disease, 823.
Corpora quadrigemina, tumors in, 991; lesions of,
951.
Corpulence, 431.
Corpus caUosum, lesions of, 949.
Corrigan's disease, 796.
Corrigan pulse, 801.
Coryza, acute, 593.
Costiveness, 525.
Cough Balne's, 449; barking, of puberty, 1081;
goose, 859; hysterical, 1081; in acute bronchitis,
602; in chronic bronchitis, 604; in pertussis, 149;
in phthisis, 323; during aspiration of pleural effu-
sion, 654; in pneumonia, 175; paroxysmal, in
bronchiectasis, 608; paroxysmal, in fibroid phthi-
sis, 336; stomach, 462.
Country fever, 386.
Coup de soldi, 385.
Cow-pox, 123.
Cracked-pot sound, 330.
Cramp, shoemaker's, 1074; writer's, 1072.
Cramps in muscles, in cholera, 232; in gout, 405; in
chronic Bright's disease, 699.
Cranio-sclerosis, 429.
Cranio-tabes, relation to congenital syphilis, 429;
in rickets, 429.
Craniotomy in brain tumors, 992; in cerebral hemor-
rhage, 980; in birth palsies, 912, 918; in lesions of
optic nerve, 1009.
Craw-craw, 47.
Creeping eruption, 56.
Cretinism, 768; endemic, 769; sporadic 768.
Cretinoid change, 768.
Crises, gastro-intestinal, in angio-neurotic oedema,
1103; in locomotor ataxia, 891; in purpura, 745;
nasal, in tabes, 892.
Crisis, in pneumonia, 174; in relapsing fever, 110;
in typhus fever, 108.
Crossed or alternating paralysis, 951, 973.
Crossed sensory paralysis, 952.
72
Croup, memliranous, 202; spasmodic, .599.
Croupous enteritis, 500.
Croupous pneumonia, 164.
Crura cerebri, lesions of, 951, 973.
Crural angina of Walton, 853.
Crutch paralysis, 1036.
Cruveilhier's palsy, 901.
Cry, epileptic, 1061; hydrocephalic, 302; hysterical,
1081; in congenital syphilis, 270.
Cryoscopy, 685.
Cryptogenetio septictemia, 215.
Crystalline-pox, 119.
Cuban itch, 113.
Curschmann' s spirals, 611, 613.
Cutaneous nerve, external, disease of, 1038.
Cyanosis, in acute tuberculosis, 300; in congenital
heart-disease, 845; in diabetes, 417; in emphy-
sema, 636;. and polycythsemia, 762; traumatic,
662.
Cycloplegia, 1014.
Cynanche maligna, 193.
Cynobex hebetica, 1081
Cystic disease, of kidney, 715; of liver, 569.
Cystic duct, obstruction of, 551.
Cysticercus cellulosaj, 31; ocular, 32; subcutaneous,
32; general, 32; cerebro-spinal, 32.
Cystin calculi, 679, 710.
Cystinuria, 679.
Cystitis, in locomotor ataxia, 892; in transverse
myelitis, 946; tuberculous, 347.
Cysts, chylous, of mesentery, 533; dermoid, 661;
in kidneys, 715; of brain, 989; of liver, 569; por-
encephalic, 986; pancreatic, 577; of brain, throm-
botic, 978.
Cytodiagnosis in general paralysis, 900.
Cytoryctes vacciniae, 125; C. variolae, 113.
Cytozoa, 1.
Dacryoadenitis (see Lachrymal, Glands).
Dancing mania, 1053.
Dandy fever (dengue), 156.
Davainea Madagascariensis, 29.
Day-blindness, 1008; in scurvy, 752.
Deaf-mutism after cerebro-spinal fever, 163.
Deafness, in cerebral tumor, 991; in cerebro-spinal
meningitis, 163; in hysteria, 1081; in Meniere's
disease, 1024; in scarlet fever, 136; in tabes
dorsalis, 891; nervous, 1024.
Death, modes of, in tuberculosis, 338.
Death, sudden, after sera injections, 205; in angina
pectoris, 840; in aortic insufficiency, 800; in
coronary artery disease, 824; in enlarged thymus,
772; in myocardial disease, 828; in pleural effu-
sion, 648; in rheumatic fever, 225; in status
lymphaticus, 755; in typhoid fever, 96.
Debility, nervous (see Neurasthenia), 1086.
Decubitus, acute, 970; (bed-sores) in transverse
myelitis, 945.
Degeneration, reaction of, 881; in neuritis, 1003;
in facial paralysis, 1021.
Deglutition, difficult (see Dysphagia).
Deglutition pneumonia, 621.
Delayed resolution in pneumonia, 185.
Delayed sensation in tabes, 891.
Delhi boil, 9.
Delirium, acute, 1041 ; acute, in lead-poisoning, 378;
cordis, 96, 832, 834; expansive, 897; in acute
1122
INDEX.
rheumatism, 224; in pneumonia, 179; in t}T>hoirl
fever, 85; in typhus fever, 107; tremens, 371.
Deltoid, paralysis of, 1036.
Delusional insanity after pneumonia, 180.
Delusions of grandeur, 897.
Dementia paralytica, 895; syphilis and, 269, 272,
896.
Demodex folliculorum, 52.
Dendrites, (protoplasmic processes), 867.
Dengue, 156.
Dentition, in congenital sjiahilis, 271; in mercurial
stomatitis, 438; in rickets, 429.
Dercum's disease, 432.
Dermacentor americanus, 53.
Dermamyiasis linearis migrans oestrosa, 56.
Dermatitis, exfoliative form, 136; protozoic, 2.
Dermatobia, 56.
Dermato-myositis, 1111.
Dermatose parasitaire, 47.
Desquamation, in measles, 143; in rubella, 146; in
scarlet fever, 134; in small-pox, 117; in typhoid
fever 74.
Deviation, secondary, 1015.
Devonshire coUc, 375.
Dextrocardia, 843.
Diabetes insipidus, 424; heredity in, 424; in ab-
dominal tumor, 424; relation of, to brain sjiihihs,
424; in tuberculous peritonitis, 424.
Diabetes melUtus, 408; acute form, 414; bronzing
in, 417; chronic form, 414; coma in, conjugal,
417; diet in, 420; dietetic form, 414; experimen-
tal, 410; gangrene in, 417; hereditary influences
in, 409; in obesity, 410; in children, 417; li-
pogenic form, 414; metabolism, 411; neiu-otic
form, 414; pancreas in, 413; pancreatic form,
414; paraplegia La, 418; perforating ulcer in, 417;
theories of, 412; urine in, 415.
Diabetes, phosphatic, 680.
Diabetic, centre in medulla, 410; cirrhosis, 413;
coma, 417; phthisis, 412; tabes, 418.
Diacetic acid, 416, 682.
Diaphragm, paralysis of, 1034; degeneration of
muscle of, 1034.
Diarrhoea, 497; acute dyspeptic, 506; alba, 500;
bacteria in, 505; chronic, treatment of, 503;
chylosa, 500; endemic, of hot countries, 51; in
children, treatment of, 509; in cholera, 231; in
dysentery, 244; fermentative, 506; in hysteria,
1082; inflammatory, 508; in phthisis, 334; in ty-
phoid fever, 79; in uramia, 685; nervous 498; of
Cochin-China, 51; tubular, 530; henteric, 499;
summer, 505.
Diathesis, gouty, 404; hsemorrhagic, 743; Uthic
acid, 677; tuberculous or scrofulous, 293; uric
acid, 677.
Diazo-reaction in typhoid fever, 87.
Dicrotism of pulse in typhoid fever, 70, 76.
Diet, in chronic dyspepsia, 463; in constipation,
527; in convalescence from tjTshoid fever, 104;
in diabetes, 420; in gout, 406; in infantile
diarrhcEa, 510; in obesity, 432; ia scurvj% 752;
in tuberculosis, 356; in typhoid fever, 99.
Dietl's crises, 666.
Digestive system, diseases of, 434.
Dioctophyme gigas, 51.
Diphtheria, 192; atypical forms of, 200; of audi-
tory meatus, 203; of conjunctiva, 203; and
croup, 199; bacillua of, 194; contagiousness of,
193; hemiplegia in, 204; immunity from, 195,
210; in animals, 194; laryngeal, 202; latent, 200;
nephritis in, 204; neuritis in. 204; nasal. 201;
pharyngeal, 200; of skin, 203; systemic infection,
201; antitoxin treatment of, 209; of wounds,
203.
Diphtheritic, coHtis, 500; membrane, histology of,
199; processes in pneumonia, 172; processes in
typhoid fever, 90.
Diphtheritis, 196.
Diphtheroid inflammations, 196.
Diplegia, facial, 1020; in children, 910.
Diplococcus intracellularis meningitidis, 159.
Diplococcus pneumonioe (micrococcus lanceolatus,
pneumococcus), 167; in empyema, 649; in endo-
carditis, 788; in peritonitis, 581.
Diplopia (see Double Vision), 1016.
Dipsomania, 369.
Dipylidium eaninum, 29.
Disinfection, in diphtheria, 207; in typhoid fever,
97.
Dissecting aneiirism, 854.
Disseminated sclerosis, 930.
Distomes, varieties of, in man, 26, 27.
Distomiasis, 26; hsemic, 27; hepatic, 26; intestinal,
27; pulmonary, 26.
Ditfrich's plugs, 605.
Diuresis, 424.
Diver's paralysis, 937.
Diverticula of oesophagus, 456; of colon, 532.
Diverticulitis, 533.
Dorsodj-nia, 397.
Dothienenterite, 57.
Double heart, 843.
Double vision, 1016; in ataxia, 889; in chronic
Bright 's disease, 699.
Dracontiasis, 49.
Dracuneulus medinensis, 49.
Drainage and diphtheria, 193; and tonsillitis, 445.
Dreamy state in epilepsy, 1062.
Dropsy, cardiac, treatment of, 818; in anaemia
(oedema), 726; in acute Bright's disease, 688; in
aortic insufficiency, 799; in aortic stenosis, 803;
in cancer of stomach. 482; in chronic Bright's
disease, 699; in mitral insufficiency, 806; in mitral
stenosis, 811; oily, 431; in phthisis, 334; in
scarlet fever, 135.
Druesetifieber, 365.
Drug-rashes, 137, 743.
Drunkenness, diagnosis of, from apoplexj', 369, 975.
Dry mouth, 441.
Dulness, movable, in pleural effusion, 647; in
pneumothorax, 659.
Dumb ague, 24.
Dum-dum fever, 9.
Duodenal ulcer, 470; diagnosis of, from gastric,
476.
Duodenum, defect of, 521; ulcer of, 470.
Dura mater, diseases of, 923; haematoma of, 923.
Durande's mixture, 555.
Duroziez's murmur, 801.
Dust, diseases due to, 629, 631; tubercle bacilli in,
287.
Dwarfs, tj^pes of, 774.
Dysacusis, 1023.
Dysbasia angio-sclerotica of Erb, 853.
INDEX.
1123
Dysentery, amoebic or tropical, 2; abscess of liver
in, 4; amoebaj in, 2; bacillary, 242; acute catarrh-
al, 245; diphtheritic, 245.
Dyspepsia, acute, 456; chronic, 459; nervous, 490.
Dysphagia, hysterical 1082; in cancer of the
oesophagus, 455; in hydrophobia, 256; in oesopha-
gismus, 453; in oesophagitis, 452; in pericardial
effusion, 779; in thoracic aneurism, 859; in
tuberculous laryngitis, 600; in tumors of the
mediastinum, 661.
Dyspnoea, cardiac, treatment of, 818; from aneu-
rism, 859; in emphysema, 636; hysterical, 1081,
1097; in acute tuberculosis, 299; in aortic in-
sufficiency. 799; in chlorosis, 722; in diabetic
coma, 417; in mitral insufficiency, 806; in mitral
stenosis, 811; in myocardial disease, 827; in peri-
cardial effusion, 779; in pneumonia, 174; in
phthisis, 326; in oedema of the glottis, 598; in
spasmodic laryngitis, 599; uraemic, 684.
Dystrophies, muscular, 906; clinical forms of, 907.
Ear, complications of scarlet fever, 136; affections
of, in syphilis, 268, 271; symptoms simulating
meningitis, 926, 994.
Ebstein's method in obesity, 432.
Ecchymoses, 743.
Echinococcus cyst, fluid of, 34, 37.
Echinococcus disease, 32.
Echinococcus, endogenous, 33; exogenous, 33; mul-
tilooular, 34, 37.
Echinorhynchus gigas, 51; E. moniliformis, 52.
Echokinesis, 1054.
Echolalia, 1054.
Eclampsia, 1056.
Ectopia cordis, 843.
Eczema, of the tongue, 438; in diabetes, 417; in gout,
404.
Edebohls' operation, 702.
Efferent tract, diseases of, 901.
Egyptian chlorosis, 44.
Ehrlich's reaction in typhoid fever, 87.
Eighth nerve, lesions of, 1023.
Elastic tissue in sputum, 324.
Electrical reactions, in exophthalmic goitre, 767:
in facial palsy, 1021; in Landry's paralysis, 919;
in multiple neuritis, 1003; in periodical paralysis,
1099; in poliomyelitis anterior, 916; Ln Thomsen's
disease, 1113.
Electrolysis in aneurism, 862.
FJephantiasis, 49; neuromatosa, 1005.
Emaciation, in anorexia nervosa, 1082; in gastric
cancer, 481 ; in oesophageal cancer, 455; in phthi-
sis, 329.
Embolic abscesses, 216.
Embolism, and aneurism, 854; in chorea, 1048; in
typhoid fever, 78; of cerebral arteries, 977; of
mesenteric artery, 533.
Embryocardia, in pneumonia, 177; in typhoid
fever, 78.
Emphysema, 633; acute vesicular, 638; atrophic,
638; compensatory, 633; hypertrophic, 634;
idiopathic, 634; interstitial, 638; large-lunged,
634; substantive, 634.
Emphysema, subcutaneous, after tracheotomy, 663;
after aspiration of the pleura, 654; in gastric
ulcer, 472; in phthisis, 335; of the mediastinum,
663.
Emprosthotonos in tetanu.s, 260.
Empyema, 648; bacteriology of, 649; necessitatis,
265, 650, 861; perforation of lung in, 650; in
scarlet fever, 135.
Encephalitis, acute, 992; meningo-, fcctal, 911;
poli-, of Strumpell, 986; suppurative, 993; syphi-
litic, 272.
Encephalopathy, lead, 377.
Enohondroma of lung, 641 .
Endarteritis of spinal cord, 935.
Endocarditis, acute, 785; chronic, 792; chronic
mural, 793; in chorea, 786, 1049; infective, 786;
in the foetus, 793, 844; gonorrhoeal, 282; in pneu-
monia, 786; in puerperal fever, 786; in rheu-
matism, 223, 785; in scarlet fever, 135; in septi-
caemia, 786; in typhoid fever, 69, 78; in tubercu-
losis, 321, 786; malignant, 786; micro-organisms
in, 788; mural, 788; recurring, 786; sclerotic, 793;
simple or verrucose, 785; syphilitic, 276; ulcera-
tive, 787.
Endophlebitis, 851.
Endothelioma, mucoid, 716.
Enteric fever (see Typhoid Fever), 57.
Enteritis, catarrhal, 497; croupous, 500; diphther-
itic, 500; in children, 504; phelgmonous, 501;
membranous or tubular^ 530; ulcerative, 501. .
Enteroclysis in cholera, 233.
Enterocolitis, 508.
Enteroliths, 522; as a cause of appendicitis, 513;
in sacculi of colon, 526.
Enteroptosis, 528, 665, 1091.
Entozoa (see Animal Parasites), 1.
Eosinophilia in ankylostomiasis, 46; in leukaemia,
736; in trichiniasis, 42.
Ependymitis, purulent, 302.
Ephemeral fever, 363.
Epidemic haemoglobinuria, 270, 671, 747.
Epidemic roseola, 145.
Epidemic stomatitis, 367.
Epididymitis (see Orchitis), 277, 348.
Epilepsia, larvata, 1062; nutans, 1032.
Epilepsy, 1058; and alcoholism, 1060; and syphilis,
1060, 1063; heredity in, 1059; in chronic ergo-
tism, 383; in general paresis, 898; in lead-poison-
ing, 378; in Raynaud's disease, 1101; Jacksonian,
883, 1063; masked, 1062; post-epileptic symptoms
of, 1062; procursive, 1061; reflex, 1060; rotatory,
1061; spinal, 910; surgical treatment of, 1066.
Epileptic fits, stages of, 1061.
Epistaxis, 595; in Bright's disease, 699; family
form of, 595, 749; in haemophilia, 749; in scurvy,
752; in typhoid fever, 84; " renal," 669; vicarious,
596.
Erb-Gold flam's symptom-complex, 1113.
Erb's syphilitic spinal paralysis, 913.
Ergotism, 383; convulsive, 383; gangrenous, 383.
Erosion of teeth, 438.
Eructations, nervous, 490.
Eruptions (see Rashes).
Erysipelas, 210; abscess in, 212; after vaccination,
126; facial, 211; in typhoid fever, 89; migrans,
212; puerperal, 211.
Erythema, exudativum, 744; infectiosum, 146; in
pellagra, 384; in typhoid fever, 75; in tonsilUtis,
446.
Erythrocythaemia, 748, 762.
Erythromelalgia, 1071, 1102.
1124
INDEX.
Eschar, sloughing, in hemiplegia, 970.
Eustrongylus gigas, 51.
Exaltation of ideas in general paresis, 897.
Exanthematic tj-phus, 105.
Exfoliative dermatitis, 136.
Exophthalmic goitre, 765; acute form, 766; diminu-
tion of electrical resistance in, 767; flushing in,
767; pigmentation in, 767; tachycardia in, 766;
tremor in, 767.
Exophthalmos, 766.
Extract of Jez, use of, in tjT)hoid fever, 102.
Extra-systole of heart, 834.
Eye, motor nerves of, paralysis of, 1013; spasm of,
1014.
Eye-strain in migraine, 1067.
Eyes, conjugate deviation of, in brain tumor, 991;
in apoplexy, 971; in tuberculous meningitis,
303.
Facial, asymmetry, 1030, 1104; diplegia, 1020;
hemiatrophy, 1104; hemihypertrophy, 1105;
nerve, paralysis of, 1019; paralysis from cold,
1020; paralysis from lesion of trunk of nerv^e,
1019; paralysis from lesion of cortex, 1019;
paralysis, symptoms of, 1020.
Facial spasm, 1022.
Facies, Hippocratic, 582; leontina, in leprosy, 362;
in mouth-breathers, 449; Parkinsonian, 1043;
syphilitic, 270; in typhoid fever, 72.
Faecal, accumulation, 521, 526; concretions, 513,
526; vomiting, 522.
Faeces, bacteria in, 505; in jaundice, 535.
Faith healing, 1095.
Fallopian tubes, tuberculosis of, 348.
Famine fever (see Relapsing Fe-ver), 109.
Farcy, 261 ; acute, 262 ; chronic, 263.
Farcy-buds, 263.
Farre's tubercles, 568.
Fasciola hepatica, 26.
Fat embolism in diabetes, 418.
Fat necrosis, 575; of pancreas, in diabetes, 413.
Fatty degeneration, of arteries, 847; of liver, 570;
of the new-born {Buhl's disease), 747.
Fatty degeneration of heart, 82ai in anaemia, 726.
Fatty stools, 575.
Febricula, 363.
Febris, carnis, 104; recurrens, 109.
Fehling's test for sugar, 415.
Fermentation, test for sugar, 415.
Fetid stomatitis, 435.
Fetor oris, 439.
Fever, aphthous, 367; bilious remittent, 20; black-
water, 22; break-bone, 156; cachexial, 9; camp,
105; cerebro-spinal, 157; in cholera, 231; country,
386; dandy, 156; dum-dum, 9; entero-mesenteric,
57; ephemeral, 363; famine, 109; Florida, 386;
gastric, 457; glandular, 365; hay, 594; hospital,
105; hysterical, 1084; jail, 105; pernicious mala-
rial, 21; in pneumonia, 172; in acute pneumonic
phthisis, 314, 316; in acute miharj' tuberculosis,
299, 300, 302; in primary multiple neuritis, 1000;
in meningi tic tuberculosis, 302; petechial. 157; in
pulmonary tuberculosis, 327; mahgnant purpuric,
157; in pyaemia, 217; in pylephlebitis, suppura-
tive, 566; in intermittent fever, 16; in relapsing
fever, 110; in remittent fever, 20; in scarlet
fever, 132; in septicaemia, 214; in small-pox, 115;
in sun-stroke, 386; in appendicitis, 514; in sec-
ondary syphilis, 267; in typhoid fever, 72; in
typhus fever, 108; in yellow fever, 236; lung, 164;
malarial, 10; miliary, 367; Malta, 247; Mediter-
ranean, 248; mountain, 366; Neapolitan, 248;
putrid malignant, 57; relapsing, 109; rock, 248;
seven-day, 109; ship, 105; slow nervous, 57;
splenic, 252; spotted, 105, 157; tick, 53; trypano-
some, 8; typhoid, 57; tjisho-malarial, 20, 95;
typhus, 105; undulant, 247; yellow, 233.
Fever, idiopathic intermittent, 216.
Fever, intermittent, in abscess of hver, 565; in ague,
16; in chronic obstruction of bile-passages by
gall-stones, 553; in Hodgkin's disease, 741; in
pyaemia, 217; in pyeHtis, 705; in septicaemia, 216;
in secondary sj'philis, 267; in tuberculosis, 322,
327.
Fibrinous, bronchitis, 613; pneumonia, 164.
Fibroid disease of heart, 824.
Fibroma of lung, 641.
Fibrosis, arterio-capillarj', 847.
Fievre, inflammatoire, 386; typho'ide a forme renale,
88.
Fifth nerve, paralysis of, 1017; gustatory branch,
1018; trophic changes in paralysis of, 1017.
FUaria, forms of, 47, 49, 50, 51.
FHariasis, 47.
Fingers, Hippocratic, 335.
Fish poisoning by, 383.
Fisher's brain murmur, 429.
Fistula in ano in tuberculosis, 337, 341.
Fistula, oesophago-pleuro-cutaneous, 456.
Fistula of Eck, 563.
Flat-foot, 1071.
Flatulence, in hysteria, 1082; in nervous dys-
pepsia, 492; treatment of, 466.
Flea, bite of. 54.
FHes, in tjiahoid fever, 63; parasitic, 55.
Flint's murmur, 800, 810.
Floating kidney, 529, 664.
Floor maggot, 56.
Florida fever, 386.
Flukes (see Distomes).
Foetus, endocarditis in, 793, 844; syphilis in, 269;
tuberculosis in, 287; white pneumonia of, 273;
typhoid fever in, 92.
Folie Brightique, 684.
Follicular tonsOhtis, 445.
Food (see Diet).
Food poisoning, 380.
Foot and mouth disease, 367.
Foramen ovale, patency of, 843.
Foreign bodies in appendix, 513; in intestines, 521.
"Fourth disease," 146.
Fourth nerve, 1014; paralysis of, 1015,
FragUitas ossium, 1108.
Fremitus, tactile, 176, 329, 646; vocal, 176, 637,
646; hydatid, 35.
Freund's operation, 638; theory, 634.
Friction, mediastinal, 663; pericardial, 777; peri-
toneal, 587; pleural, 330, 647; pleuro-pericardial,
330, 777.
Friedreich's ataxia, 921 ; disease, 1113.
Friedreich's sign in adherent pericardium, 783.
Frontal convolutions, lesions of, 990.
Frontal sinuses, pentastomes in, 62.
Funnel breast, 329, 449.
INDEX.
1125
Gait, ataxic, 890; goose, 681; in paralysis agitans,
1043; in pseudo-hypertrophic muscular paralysis,
906; in spastic paraplegia, 909; pseudo-tabetic,
418, 1002; steppage, in peripheral neuritis, 378,
380, 1002; in diabetic tabes, 418.
Gall-bladder, diseases of, 542; atrophy of, 552;
calcification of, 552; cancer of, 546; dilatation of,
552; empyema of, 552; forming abdominal tumor,
552; phlegmonous inflammation of, 552.
Gallop rhythm, in myocardial disease, 827.
Galloping consumption, 315.
Gall-stone crepitus, 552.
Gall-stones, 548.
Game-birds, poisoning by, 382.
Ganglia, basal, tumors of, 990.
Ganglia, dorsal root, acute hsemorrhagic inflamma-
tion of, 900.
Gangrene, in diabetes, 417; in ergotism, 383; in
pneumonia, 187; in typhoid fever, 78; in typhus,
108; local or symmetrical, 1101; multiple, 1101;
of lung, 638; of mouth, 437.
Gangrenous stomatitis, 437.
Garrod's thread test for uric acid, 400.
Gas-bacillus (see Bacillus aerogenes capsdla-
TUS).
Gasserian ganglion, extirpation of, in tic douloureux,
1070.
Gastralgia, 493.
Gastrectasis, 467.
Gastric catarrh, acute, 456.
Gastric, crises, 476, 494, 891; fever, 457.
Gastric juice, hyperacidity of, 476, 492; subacidity
of, 493.
Gastric spasm, congenital, 487.
Gastric ulfter, 470.
Gastritis, acida, 462; acute, 456; acute suppurative,
458; anacida, 462; atroplicans, 462; chronic, 459;
diphtheritic, 459; membranous, 459; mucipara,
462; mycotic, 459; parasitic, 459; phlegmonous,
458; polyposa, 460; sclerotic, 460; simple, 456;
simple chronic, 460; toxic, 458.
Gastrodiscus hominis, 27.
Gastrodynia, 493.
Gastrophilus equi, 56.
Gastrorrhagia, 487.
Gastrorrhexis, 476, 488.
Gastrotomy, 455.
Gastroxynsis, 492.
General paralysis of the insane (general paresis),
895; diagnosis of, from syphilis, 899; influence
of syphilis in, 269, 272, 896.
Genito-urinary system, tuberculosis of, 343.
Gentles, 55.
Geographical tongue, 438.
Gerlier's disease, 1025.
German measles, 145.
Giant growth, 1106.
Gigantism and acromegaly, 1106; and giants, 1106.
Gigantorhynchus gigas, 51.
Gilles de la Tourette's disease, 1054.
Gin-drinker's liver (see Cirrhosis of Liver), 556.
Glanders, 261; acute, 262; chronic, 262; diagnosis
from small-pox, 121.
Glandular fever, 365.
Glenard's disease, '528.
Glioma of brain, 988.
GHosis, 943.
Globulin in urine, 675.
Globus hystericus, 1077.
Glomerulo-nephritis, 687.
Glossitis, MoUer's, 438.
Glosso-labio-laryngeal paralysis, 904.
Glosso-pharyngeal nerve, affections of, 1026.
Glossy skin in arthritis deformans, 392.
Glottis, oedema of, 598; in Bright's disease, 699;
in small-pox, 119; in typhoid fever, 69.
Gluteal nerve, affections of, 1038.
Glycogen, formation of, 412.
Glycogenic function of liver, 412.
Glycosuria, 412, 682; gouty, 402; lipogenic, 410.
Gmelin's test, 535.
Goitre, 763; exophthalmic, 765; sudden death in,
764; lingual, 764.
GonorrhcEal arthritis, 282; endocarditis, 282; septi'
csemia and pyaemia, 282.
Gonorrhoea! infection, 281; systemic, 282.'
Goose cough in aneurism, 859.
Gout, 397; acute, 402; chronic, 403; Ebstein's theory
of, 400; guanin, of hogs, 401; hereditary influence
in, 397; influence of alcohol in, 397; influence of
food in, 398; influence of lead in, 398; irregular,
404; nervous theory of, 400; poor man's, 398;
retrocedent or suppressed, 403; rheumatic, 389;
trauma and, 398.
Gouty kidney, 694.
Graefe's sign, 766.
Grain, poisoning by, 383.
Grandeur, delusions of, 897.
Grand mal, 1058, 1060.
Granular kidney, 694.
Granulomata, infectious, of brain, 988.
Gravel, renal, 709.
Graves' disease, 765.
Green cancer, 738.
Green-sickness (see Chlorosis), 722.
Green-stick fracture in rickets, 429.
GregarinidsB, parasitic, 1.
Grinder's rot, 631.
Grippe, la, 152.
Grocco's sign, 647.
Ground itch, 45.
Gruebler's tumor, 377.
Guinea-worm disease, 49.
Gull's disease, 769.
Gummata, 267; in acquired syphilis, 269; in con-
genital syphilis, 271 ; of brain and spinal cord, 271 ;
of heart, 276; of kidneys, 277; of liver, 275; of
lungs, 273; of rectum, 276; of testis, 277.
Gummatous periarteritis, 277.
Gums, black line on, in miners, 377; blue line on, in
lead-poisoning, 376; in scurvy, 751; in stomatitis
435; red Hne on, in pulmonary tuberculosis, 333.
Gustatory paralysis, 1018.
Habit spasm, 1053; in mouth-breathers, 450.
Habitus, apoplectic, 966; phthisicus, 293.
Haematemesis, 487; causes of, 487; in cancer of
stomach, 483 ; in cirrhosis of liver, 558 ; diagnosis
from haemoptysis, 489; in enlarged spleen, 23,
487; in scurvy, 752; in typhoid fever, 79 ; in ulcer
of stomach, 474.
Haematochyluria, non-parasitic, 677; parasitic, 48.
Haematoma of dura, of brain, 923; of cord, 924; of
mesentery, 532.
1126
INDEX.
Hfpuiatomata, 749.
Haematomyelia, 936.
HaematoporphjTin, 682.
Hsematorrhacliis, 935.
Haematuria, 669; angio-neurotie renal, 347; endemic
of Egj-pt, 27; essential renal, 347; functional, 347;
in acute nephritis, 688; in chronic phthisis, 334;
in i^sorospermiasis, 2; in renal calculus, 712; in
renal cancer, 714; in tuberculosis of kidney, 346;
malarial, 22; unilateral, 669.
Haemochromatosis, 413.
Hcemocytozoa of malaria, 10.
Hsemoglobin, reduction of, in chlorosis, 722.
HsemoglobiniEmia, 671.
Hsemoglobinuria, 670; epidemic, in infants, 270,
671, 747; malarial, 22;in Raynaud's disease, 1101;
paroxysmal, 671; toxic, 670.
Hsemoglobinuric fever, 22.
Hsemo-pericardium, 784; -peritonseum, 573.
Haemophilia, 747.
Haemoptysis, causes of, 617; hysterical, 1081; at
onset of phthisis, 322; in acute broncho-pneu-
monic phthisis, 316; in acute miliary tuberculosis,
300; in aneurism, 617, 859; in aortic insufficiency,
799; in arthritic subjects, 617; in bronchiectasis,
608; in cirrhosis of lung, 630; in emphysema,
637; in mitral insufficiency. 806; in mitral ste-
nosis, 811; in pneumonia, 175; in pulmonary
gangrene, 640; in scurvy, 752; symptoms of,
618; treatment of, 619; in typhoid fever, 85;
relation to tuberculosis, 325, 617; parasitic, 26;
periodic, 617; vicarious, 617.
Hemorrhage, broncho-pulmonary. 617; cerebral,
966; from mesentery, 532; from the stomach,
487; in acute yellow atrophy, 539; in anfcmia,
729; in cirrhosis of the liver, 558; in contracted
kidney, 699; in gastric cancer, 483; in gastric
ulcer, 474; in hemophilia, 748; in hysteria, 1081,
1083; in intussusception, 524; in leuka?mia, 734;
in malaria. 22; in nephrolithiasis, 712; in the new-
born, 747; in purpura haemorrhagica, 745; in
scarlet fever, 134; in scur^•y, 752; in small-pox,
117; in splenic enlargement, 23 762; into pan-
creas, 573; into spinal cord, 936; into spinal
membranes, 935; in tuberculous pyelitis, 347;
in tuberculosis of bowels, 340; into ventricles of
brain, 968; in typhoid fever, 68, 80; in yellow
fever, 237; pulmonary, 325, 617.
Haemorrhagic diathesis, 743.
Haemorrhagic diseases of the new-bom, 747,
Hsemorrhagic typhoid fever, 91.
Haemothorax, 651.
Hair tumors in stomach, 486.
Hairy heart, 776.
Hallucinations in hysteria, 1083.
Harrison's groove in rickets, 428; in enlarged
tonsils, 449.
Har\'est-bug. 53.
Hay-asthma (hay-fever). 594.
Haygarth's nodosities, 390.
Headache, from cerebral tumor, 989; in cerebral
syphilis, 272 ; in mouth-breathers, 450 ; in ty-
phoid fever, 70 71, 85; in uraemia, 684; sick,
1066.
Head-cheese, poisoning by 381.
Head-shaking in infants, 1032.
Heart-block, 834, 837.
Heart, bovine, 798; diseases of, 785; OcrteVs treat-
ment of diseases of, 829; amyloid degeneration
of. 826; aneurism of, 830; athlete's, 797; brown
atrophy of, 826; calcareous degeneration of,
827; congenital affections of, 843; dilatation of,
820; displacement in pleuritic effusion, 645;
displacement in pneumo-thorax, 658; fatty
disease of, 825; foreign bodies in, 831; fragmenta-
tion of fibres of, 825; functional affections of, 832;
hairy, 776; hydatids of, 831; hypertrophy of,
822; hypertrophy of, in Bright's disease, 698;
in exophthalmic goitre, 766; irritable, 833; new
growths in, 831 ; palpitation of, 832; parenchyma-
tous degeneration of, 825; rapid, 835; rupture of,
S30; segmentation of, 825; syphilis of, 276, 831;
tobacco, 842; tubercle of, 349, 831; tumors of,
831; vahiilar diseases of, 793; wounds of, 831.
Heart-muscle in fevers, 825.
Heart-sounds, audible at distance, 766, 810; weak-
ness of, 827.
Heart strain, 821.
Heart-valves, congenital anomalies and lesions of,
844; rupture of. 798.
Heat, exhaustion, 385; stroke, 385,
Heberden's nodes. 391.
Hectic fever, 327.
Heel, painful, 1071.
Heller's test, 673
Helminthiasis (see .\nimal Parasites), 1.
Hemeralopia, 1008; in scurvy, 752.
Hemialbumose, 674.
Hemianacsthesia, in cerebral haemorrhage, 973; in
hysteria, 1080; in railway spine, 1097; in lesions of
internal capsule, 951; in unilateral cord lesions,
933.
Hemianopia, in aphasia, 959; functional, 1012;
heteronymous, 1009; homonymous, 1009; in
migraine, 1067; lateral, 1009; nasal, 1010; signifi-
cance of, 1012; temporal, 1009.
Hemiatrophy, facial, 1104.
Hemicrania, 1066.
Hemiopic pupillary inaction, 1012.
Hemiplegia, 966. 971; crossed, 951, 973.
Hemiplegia, infantile, 985; aphasia in, 986; cortical,
948; in diphtheria, 204; epilepsy in. 987; in hys-
teria, 1079; in malaria. 23; mental defects in, 987;
post-hemiplegic movements in, 987; spastica
cerebralis, 986; in typhoid fever, 86.
Hemiplegie Basque. 974.
Henoch's purpura, 745.
Hepatic abscess, 563; artery, enlargement of, 542;
aneurism of, 865; colic, 550; intermittent fever,
553; vein, affections of, 542.
Hepatitis, interstitial (see Cirrhosis), 556; sup-
purative, 563.
Hepatization, of lung, 170; white, of foetus, 273.
Hereditary form of oedema, 1104.
Heredity, in Bright's disease, 694; in diabetes in-
sipidus, 409: 'm Friedreich's ataxia, 921; in gout,
397; in haemophilia, 748; in paramyoclonus multi-
plex, 1 1 13 ; in rheumatic fever, 220 ; in spastic para-
plegia, 912; in syphilis, 266; in tuberculosis, 287.
Herpes, in cerebro-spinal meningitis, 161; in febric-
ula, 364; in malaria, 17; in pneumonia, 179; in
tj'phoid fever, 75; zoster, 900.
Hiccough, 1034; causes of, 1034; treatment of, 1035:
hysterical, 1081.
INDEX.
1127
High-tension pulse, characters of, 698, 851.
Hippocratic facies, 82, 582; fingers, 335; succussion,
659.
Hippus, 1067.
Hodgkin's disease, 738; intermittent fever in, 741.
Homalomyia scalaris, 55.
Hook-worm disease, 44.
Horn-pox, 119.
Hospital fever, 105.
Hour-glass stomach, 475.
Huntingdon's chorea, 1055.
Husband and wife, diabetes in, 409; tuberculosis
in, 291.
Hutchinson' s teeth, 271.
Hyaline casts in urine, 688, 693, 698.
Hybrid measles, 145.
Hybrid scarlet fever, 145.
Hydatid disease (see Echinococcus).
Hydatid thrill or fremitus, 35.
Hydrarthrosis, chronic, 283; intermittent, 1083.
" Hydrencephaloid condition," 507, 965.
Hydriatic treatment (see Hydrotherapy).
Hydrocephalus. 996; acquired chronic, 997; acute,
301. 996; angio-neurotic, 996; chronic, after
cerebro-spinal meningitis, 162; congenital, 997;
drainage in, 998; externus, 996; ex vacuo, 996;
idiopathic internal, 996; spurious, 507.
Hydrocystoma in exophthalmic goitre, 767.
Hydromyelus, 924, 943.
Hydronephrosis, 707; congenital, 707; intermittent,
666, 708.
Hydropericardium, 784.
Hydroperitonffium, 589.
Hydrophobia, 255.
Hydro-pneumothorax, 657.
Hydrops ad matulam, 409; vesicae fellse, 552.
Hydrothorax, 656.
Hymenolepsis diminuta; H. nana, 29.
Hyperacidity of gastric juice, 492.
Hyperacusis, 1023.
Hyperadrenalism, 760.
Hyperaemia of the brain, 964.
Hyperajsthesia, in ataxia, 891; in hamatomyelia,
936; in hysteria, 1080; in railway spine, 1097; in
rickets, 428; retinal, 1008; in unilateral cord
lesions, 933; of stomach, 493.
Hyperalgesia, 1089.
Hyperchlorhydria, 492.
Hyperkinesis of stomach, 490.
Hypernephroma, 714.
Hyperosmia, 1006.
Hyperpyraemia, 398.
Hyperpyrexia, hysterical, 1084; in rheumatic fever,
223; in scarlet fever, 133; in sun-stroke, 386; in
tetanus, 260.
Hyperthyrea, 765.
Hyperthyroidism, 765.
Hypertrophic cirrhosis of liver, 560.
Hypnotism in hysteria, 1086.
Hypodermic syringe in diagnosis of pleural effu-
sion, 652.
Hypoglossal nerve, diseases of, 1032; paralysis of,
1032; spasm of, 1033.
Hypoleucocytosis, in typhoid fever, 76.
Hypophysis, enlargement of, 1106.
Hypostatic congestion, of lungs, 615; in typhoid
fever, 85.
Hypothermia, in typhoid fever, 74.
Hypotonia, 891.
Hysteria, 1076; and disseminated sclerosis. 931;
contractures and spasms in, 1079; convulsive
forms of, 1077; cries in, 1081; disorders of sensa-
tion in, 1080; forms of fever in, 1084; hamoptysis
in, 1081; insanity in, 1083; joint affections in,
1083; mental symptoms of, 1083; metabolism in,
1084; metallotherapy in, 1080; needle-swallow-
ing in, 831; non-convulsive forms of. 1078; paraly-
sis in, 1078; special senses in, 1081; stigmata in,
744, 1083; traumatic 1096; visceral manifesta-
tions of, 1081.
Hysterical angina pectoris. 841.
Hystero-epilepsy, 1063, 1078.
Hysterogenic points, 1080.
Ice-cream, poisoning by, 382.
Ice, typhoid bacillus in, 61.
Ichthyosis lingualis, 439.
Icterus (see Jaundice); gravis, 538; neonatorum,
538.
Idiocy, in infantile hemiplegia, 987; amaurotic, 912.
Idiopathic anaemia of Addison, 724.
Idiopathic intermittent fever, 210.
Ileo-caecal region, in typhoid fever, 82; in appendi-
citis, 514; in primary tuberculosis of bowel, 341.
Ileo-coHtis, 508.
Ileus (see Strangulation of Bowel), 519;
hysterical, 1082.
Imbecility in infantile hemiplegia, 987.
Imitation in chorea, 1046.
Impetigo, contagious, and ulcerative stomatitis,
435.
Impotence, in diabetes, 419; in locomotor ataxia,
892.
Impulsive tic, 1054.
Incarceration of bowel, 519.
Incoordination, of arms, 890; of legs, 890.
Indians, American, chorea in, 1045; consumption
in, 285; small-pox among, 112.
Indicanuria, 680.
Indigestion, 456; acute intestinal, 506.
Infantile, convulsions, 1056; paralysis, 914; scurvy
753.
Infantilism, 270, 769, 773; Lorain type of, 774;
myxcedematous, 774; pancreatic, 774.
Infarcts, septic, of coronary arteries, 824.
Infection, definition of, 213.
Infectious diseases 57; of doubtful nature, 363.
Inflation of bowel in intussusception, 525.
Influenza, 152; appendicitis in, 155; cholelithiasis
in, 155; and typhoid fever, 90; peritonitis in, 155.
Infusoria, parasitic, 25.
Inhalation pneumonia (see Aspiration Pneu-
monia), 621.
Inoculation, against small-pox, 112, 119; pro-
tective, in cholera, 229; preventive, in hydro-
phobia, 257; preventive, in plague, 242; pre-
ventive, in pneumonia, 169; preventive, in typhoid
fever, 98; tuberculosis transmitted by, 289.
Insane, general paralysis of, 895.
Insanity, delusional, 684; post-febrile, 86; in small-
pox, 119.
Insanity, relation of drink to, 370; relation of
chronic phthisis to, 334; relation of heart-disease
to, 800.
1128
INDEX.
Insects, parasitic, 53.
Insolation, 385.
Insular sclerosis, 930.
Intention tremor (see Volitioxal Tremor).
Intercostal neuralgia, 1070.
Intermittency of heart action, 834.
Intermittent claudication, 841, 853.
Intermittent fever, 16; forms of (see Fetzb).
Intermittent hepatic fever, 5-53.
Intermittent hydrarthrosis, 1083.
Intermittent lameness, 853.
Internal capsule, lesions of, 949.
Internal carotid arterj-, blocking of. 979.
Intestinal casts, 531; sand, 532; coils, tumor formed
by, 311; obstruction, 519.
Intestines, diseases of, 497; actinomycosis of, 264;
dilatation of, 531.
Intestines, haemorrhage from, in tjTphoid fever,
68, 80; in dysenterj-, 5, 244; in tuberculosis of
bowel, 340; in intussusception of, 524; in ulcera-
tion of, 501.
Intestines, infarction of, 533; intussusception of,
519, 524; invagination of, 520; miscellaneous
afifections of , 530 ; new growths in, 521; ulcers of,
501.
Intestines, obstruction of, 519, 584; acute, 522;
chronic, 522; by enteroliths, 522; by foreign
bodies, 521 ; by gall-stones, 522, 555; by lipomata,
521.
Intestines, perforation of, in tjTjhoid fever, 67, 81.
Intestines, primarj- tuberculosis of, 292, 340;
strangulation of, 519, 524; strictures and tumors
of, 521 ; twists and knots in, 520.
Intoxication, definition of, 213.
Intoxications, 369.
Intussusception, 519, 524.
Invagination, 520; post-mortem, 520.
Inverse t>T)e of temperature in acute tuberculosis,
299; in tj-phoid fever, 72.
Iridoplegia, 1014; accommodative, 1014; reflex,
1014.
Iritis, s>-philitic, 268, 271.
Itch, Cuban, 113; insect, 52; Philippine, 113.
Itching, of feet in gout, 405; of eyeballs in gout,
405; of skin in Bright 's disease, 699; of skin in
jaundice, .535; preicteric, 535; in diabetes, 417;
in exophthalmic goitre, 767; in uraemia, 684; in
Hodgkin's disease, 741.
Ixodes ricinus, 53.
Ixodiasis, 53.
Jacksonian epilepsy, 883, 1063.
Jail fever, 105.
Jaundice, 534; black, 535; catarrhal, 542; choluria
in, 535; from cirrhosis of liver, 559, 561 ; congen-
ital acholuric form of, 537 ; epidemic form of,
364: infectious, 364; from acute yellow atrophy,
538; from cancer of liver, 569; in diphtheria, 204;
from gaU-stones, 551, 553; hereditan.-, 537; in
influenza, 154; in pneumonia, 181; and purpura,
536, 743; in WeH's disease, 364; malignant, 538;
of the new-bom, 538; obstructive, 534; in sj-ph-
ilis, 275; toxsemic, 536; in tj-phoid fever, 83;
xanthelasma in, 535; in yellow fever, 236.
Jaw clonus, 903.
Jigger, .55.
Joints (see Arthritis).
Jumpters, 1055.
"June cold," 594.
Kahler's disease, 674.
Kakke, 249.
Kala-azar, 9.
Katayama's disease, 28.
Keloid of Addison, 1109.
Keratitis, in small-pox, 120; interstitial, of in-
herited syphilis. 271.
Kernig's sign, 163.
Kidney, diseases of, 664; amyloid or lardaceous
disease of, 702; cancer of, 714; cardiac, 668;
circulatory disturbance in, 667; cirrhosis of, 694;
congenital cystic, 715; congestion of, 667; con-
tracted, 694; cyanotic induration of, 668; cystic
disease of, 715; disk-shaped, 664; echinococcus of,
37; floating. 664; fused, 664; gouty, 694; granular,
694; horseshoe, 664; large white, 692; malforma-
tions of, 664; movable, 664; palpable, 664;
rhabdo-myoma of, 714; sarcoma of, 714; scrofu-
lous, 347, 704; sigmoid. 664; small white kidney,
692; surgical kidney. 704; syphilis of, 277;
tul>erculosis of 345; tumors of, 713.
Klebs-lAxfflcr bacillus, 194.
Knee-jerk, loss of, in ataxia 891; in diphtheria, 204.
Koch treatment of tuberculosis, 356.
Kopftetanus, of Rose, 260.
Koplik's sign, 142.
KoesakofTs syndrome, 370, 1002.
Kubisagari, 1025.
Labyrinthine (Hsea,«e, 1024.
Lachrymal gland in mumps, 147; in Mikulicz's
disease, 442.
" Lacing" liver, 572.
LacunEP of Marie. 967.
Lacunar ton.«illitis, 445.
La grippe, 152.
Lamblia intestinalis. 25.
Lameness, intermittent, 85.3.
Laminectomy in compression myelitis, 940; in
tumors of the cord, 942.
Lnndry's paralysis, 918.
Laparotomy, in cirrhosis of the liver, 563; in typhoid
fever, 103.
I>arva migrans, 56.
Larvip of flies, dLseases caused by (myiasis), 55.
Laryngeal crises, 892.
Larj'ngismus stridulus, 598; identity of, with en-
larged thymus, 772.
Larj'ngitis, acute, catarrhal, 596; chronic, 597;
CEdematous, 598; spasmodic, 598; syphilitic, 601;
tuberculous, 600.
Larj-nx, diseases of, 596; adductor paralysis of,
1028; ansesthesia of, 1029; hypersesthesia of,
1029; paralysis of abductors of, 1027; spasm of the
muscles of, 1028; unilateral abductor paralysis
of. 1028.
Latah, 10,55.
Lateral sclerosis, primary, 909; amyotrophic, 901.
Lateritious deposit, 677.
Lath>Tism. 384.
Lead. coUc, 377; in the urine. 375.
Lead-palsy, 377; localized forms of. Zil .
Lead-poisoning. 375; acute. 376; arterio-sclerosis in,
378; cerebral symptoms in, 378; chronic, 376;
INDEX.
1129
convulsions from, 378; gouty deposits in. 379;
treatment of, 379.
Lead-workers, prevalence of gout in, 398.
Leichen-tubercle, 290.
Leishman body, 9.
Leontiasis ossea, 1107.
Lepra alba, 362; mutilans, 362.
Leprosy, 359; anoesthetic, 362; bacillus leprae in,
360; contagiousness of, 361 ; macular form of,
362; tubercular, 362.
Leptomeningitis, acute cerebro-spinal, 925; chronic,
928; infantum, non-tuberculous, 928.
Leptothrix in mouth. 264.
Leptus autumnalis, 53.
Leucin, 539.
Leucocythaemia, 731.
Leucocytosis, in anaemia, 721 ; chlorosis, 722; cere-
bro-spinal meningitis, 161; diphtheria, 201; em-
pyema, 649; erysipelas, 212; Hodgkin's disease,
741; leukaemia, 735; malaria, 24; measles, 143;
pyaemia, 217; pneun.onia, 177;- pleurisy, 648;
rheumatic fever, 222; scarlet fever, 133; stomach
cancer, 482, 485; in trichiniasis, 42; in tuber-
culosis (acute), 300; in tuberculosis (chronic pul-
monary), 333; absence of, in typhoid fever, 76, 93;
in whooping-cough, 151.
Leucoderma, 1109.
Leuco-keratosis, mucosa; oris, 439.
Leuconychia, 1002.
Leucopenia in typhoid fever, 76.
Leukaemia, 731; acute, 737; lymphatic, 736; blood
in, 735; congenital, 732; heredity in, 732; in
animals, 732; in pregnancy, 732; myelogenous,
731; pseudo-, 738; spleno-meduUary, 734.
Leukanaemia, 737.
Leukoplakia buccalis, 439.
Leyden's crystals, 611, 613.
Lienteric diarrhcea, 499.
Life assurance and albuminuria, 675; and syphilis,
281.
Lightning pains in ataxia, 889.
Lineae atrophicae, 75.
Lingual corns, 439.
Linguatula rhinaria, 52; L. .serrata, 52.
Lipaciduria, 682.
Lipaemia, 412, 418.
Lipoma of the spinal cord, 941.
Lipothymia, 583.
Lips, tuberculosis of, 339; chancre of, 266.
Lipuria, 416. 682.
Lithffimia, 677.
Lithic-acid diathesis, 677.
Lithuria, 677.
Little's disease, 910.
Liver, abscess of, 4,563; actinomycosis of, 264; acute
yellow atrophy of, 538; amyloid, 571; antemia of,
540; angioma of, 569; cardiac, 541; anomalies in
form and position of, 572; cysts of, 569; fatty, 570;
gummata of, 274; hepato-phlebotomy in con-
gestion of, 542; hydatids of, 35; hyperaemia of,
540; infarction of, 542; melano-sarcoma of, 568;
new growths in, 567; nutmeg, 541; passive con-
gestion of, 541; periodical enlargement of, 541;
primary cancer of, 567; psorospermiasis of, 1;
pulsation of, 541; sarcoma of, 568; secondary
cancer of, 568; syphilis of, 274; tuberculosis of,
341; in typhoid fever, 68, 83.
Liver, cirrhosis of, 556; alcoholic 557; ascites in,
559; atrophic. 557; capsular form. 562; in diabetes
413; fatty. 557; haemorrhage from stomach in
558; hypertrophic 560; syphilitic, 275, 562; in
children, 557; jaundice in. 559; toxic symptoms
in. 559; with cancer, 570; tuberculous, 342.
Liver, diseases of, 534.
Liver dulness. obliteration of, in perforative peri-
tonitis, 82. 582.
Liver, movable. 529, 572.
Living skeletons, 903.
Lobar pneumonia, 164.
Lobstein's cancer, 715.
Localization, cerebral, 874; spinal, 871.
Localized peritonitis, 584.
Lock-jaw, 258, 1018.
Lock-spasm, 1073.
Locomotor ataxia, 886; ataxic stage of, 890; bladder
symptoms in, 889; gastric crises in, 891; hemi-
plegia in, 892; incipient stage of, 889; laryngeal
crises in, 892; nasal crises in, 892; paralytic stage
of, 892; paresis in, 892; rectal crises in, 891; re-
lation of syphiHs to, 886.
I>ong thoracic nerve, affections of, 1036.
Loose shoulders, 907.
Lucilia macellaria, 55.
Ludwig's angina, 444.
Lues venerea (syphilis), 265.
Lumbago, 396.
Lumbar neuralgia, 1071.
Lumbar plexus, lesions of, 1038.
Lumbar puncture of Quincke, 163, 928, 998.
Lung, abscess of, 640; embolic, 640.
Lung, actinomycosis of, 264; albinism of, 635;
brown induration of, 615; cancer of, 641; carni-
fication of, 622; cirrhosis of, 628.
Lung, di.seases of, 614; stones, 319.
Lung fever, 164.
Lungs, congestion of, 614;' hypostatic, 615.
Lungs, ecldnococcus of, 36.
Lungs, gangrene of, 638; abscess of brain in, 639.
Lungs, new growths in, 641; in cobalt-miners, 642.
Lungs, hirmorrhagic infarction of, 618; oedema of,
616; splenization of, 615, 622; syphilis of, 273;
tuberculosis of, 312.
Lupinosis, 384.
Lymph glands, tuberculosis of, .304.
Lymphadenitis, general tuberculous, 306; local
tuberculous, 306; simple, 660; suppurative, 660.
Lymphadenoma, general, 738.
Lymphatic state, 755.
Lymphatism, 448, 755.
Lymphocytosis, in cerebro-spinal fluid, 900.
Lymphoma, malignant, 739.
Lympho-sarcoma, 739, 742.
Lymph-scrotum, 49.
Lymph, vaccine, 127.
Lymph vessels, dilatation of, 49.
Lyssa, 255.
I yssophobia. 258.
Maculae ceruleae, 54, 75.
Macular syphilides, 268.
Maidismus, 384.
Main en griffe, 903, 925.
Maize, poisoning by (pellagra), 284.
Maladie de Hanot, 560; de Woillez, 614.
1130
INDEX.
Malarial cachexia, 15. 23.
Malarial fever. 10; accidental and late lesions of,
15; sestivo-autiimnal, 20; algid form of. 22;
comatose form of. 21; continued and remittent
form of. 20; description of the paroxysm in. 16;
geographical distribution of, 10; hEPmorrhagic
form of, 22; intermittent. 16; nephritis in. 16;
pernicious. 15. 21; pneumonia in. 16: quartan. 17;
quotidian. 17; season in. 10; specific germ of, 10;
tertian. 17.
Malarial hsemoglobinuria, 22.
Malarial nephritis. 16.
MaUein. 263.
Malta fe%-er. 247.
Mammarj- glands. h>'pertrophy of, in tuberculosis.
334; tuberculosis of. 349.
Mania a potu. 371.
Mania, Bell's, 1041.
Marriage, question of, in ha?mophilia, 749; in
syphilis, 281; in tabes dorsalis, 894; in tubercu-
losis, 351.
Marrow of bones, in small-pox. 115; in leuksemia,
732; in pernicious anaemia, 726.
Masque des femmes en^iente*, 758.
Massai disease, 50.
Mastication, spasm of the muscles of, 1018.
Mastitis in enteric fever, 88; chronic, 334.
McBurney's tender point. 515.
Measles. 140; abortive, 143; attenuated, 143; black,
143; buccal spots in. 142; contagiousness of. 141;
desquamation in. 143; eruption in, 142; German,
145; malignant, 143; period of incubation in,
141.
Measly meat, examination of, 30.
Meat, poisoning by, 381; tuberculous infection by,
292; inspection of, for trichinan, 41.
Mecfcel's diverticulum. 519.
Median nerve, affections of, 1037.
Mediastinal friction, 663. .
Mediastino-pericarditis, indurative. 663.
Mediastinum, affections of, GOO; abscess of, 662;
cancer of, 661; emphysema of, 663; pleural effu-
sion in, 662; sarcoma of. 661; tumors of, 661.
Mediterranean fever, 248.
Medulla oblongata, lesions of, 952; tumors of, 991.
Megalo-cephaly, 1108.
Megalocytes, 728.
Megalogastric, 467.
Mela>na in duodenal »ilcer. 474; in t>-phoid fever, 80;
in tuberculosis of bowels, 340; neonatorum, 747.
Melano-sarcoma of liver, 568; of lungs, 641.
Melanuria, 680.
Melasma suprarenale, 758.
Meniere's disease, 1024.
Meningeal ha5morrhage, 968; in birth palsies, 9^0.
Meninges, affection of, 923.
Meningitis, acute cerebro-spinal, 925: basilar, 301;
epidemic cerebro-spinal, sporadic cerebro-spinal,
157,928; in erjsipelas, 212; in gout. 405; granu-
lar, 301; lepto, 928: in tj-photd fever. 69. 85;
simple, of infants, 928; posterior basic. 928;
serous, 996; s\-philitic, 272; tuberculous, 301.
Meningococcus, 159.
Meningo-encephalitis, tuberculous, 302.
Meralgia paraesthetica, 1038.
Mercurial, tremor, 1045; stomatitis, 437.
Merjxismus, 491.
Mesaortitis, 848.
Mesenteric arterj-, aneurism of, 533, 865; embolism
of, 533; thrombosis of. 533.
Mesenteric glands, tuberculosis of. 308; tuberculous
tumors of, 312; in t\-phoid fever, 68.
Mesenteric veins, diseases of. 533.
Mesenteric vessels, affections of. 533.
Mesentery, chylous cysts of, 533; affections of, 532.
Mesogonimus heterophyes, 27.
Metallic echo, 659; tinkling, 331, 659.
Metallotherapy, 1080.
Metastatic abscesses. 216
Metasj-philitic affections, 269-
Metatarsalgia, 1071.
Meteorism in t>-phoid fever, 80; treatment of, 102.
Micrococci, in Malta fever. 248.
Micrococcus, catarrhalis, 593; lanceolatus, 164, 167.
215,216,623; melitensis.248; thecalis, in I/ondrya
paralysis, 918.
Microcytes. 728.
Micromelia, in cretinism, 769.
Middle cerebral arten.-, embolism and thrombosis
of, 979.
Migraine. 1066; treatment of, 1068.
Mikulicz's disease. 442.
Miliar>- absce.^ses in typhoid fever, 68.
Miliary aneurism, 967.
Miliar>- fever, 367; epidemics of, 367.
Miliao' tubercle, 295; tuberculosis, acute, 298;
tuberculosis, chronic, 318.
Milk and scarlet fever. 131; and typhoid fever. 62;
products, poisoning by, 382; sickness, 365; tuber-
culous infection by, 292.
Mind-blindness, 959.
Mind-deafness. 959.
Miner's anaemia or cachexia, 44; lung, 631; nystag-
mus. 1014; cancer of lung, 642.
Mitchell. Weir, treatment in hysteria, 1086.
Mitral incompetency, 804.
Mitral stenosis, 808; chorea and, 808; paralysis of
recurrent lar>ngeal in, 811; presystolic murmur
in, 810; rheumatism and, 808.
Mobt sounds in pulmonary tuberculosis. 330.
M6ller"s glossitL*. 438.
Monophobia. 1089.
Monoplegia, cerebral, 883. 947; facial, 1019; in
hysteria, 1079; in traumatic neuroses, 1097.
Montaigne on renal colic. 71 1 .
Montreal General Hospital, stati.«tics of hsemorrha-
gic small-pox, 118; of pneumonia. 187; of rheuma-
tic fever. 219.
Montreal small-pox epidemic 1885-'86, 128.
Morbilli 140; sine morbillL«, 143.
Morbus, ca'ruleus, 845.
Morbus, co-xae senilis, 392; erronum, 54.
Morbus maculosus, 743; neonatorum, 747; of
Werlhof. 745.
Morphia habit, 373; treatment of, 374,
Morphinism, 373.
Morphinomania, 373.
Morphtt-a. 1109.
Mortality, in cerebro-spinal meningitis, 164; in
pneumonia, 187; typhoid fever. 96; in whooping-
cough. 151; in yellow fever, 238.
Morton's painful foot, 1071.
Morran's disease, 944.
Mosquitoes, forms of, 13, 235.
INDEX.
1131
Mosquitoes, relation of, to filaria disease, 48; to
malaria, 13; to yellow fever, 235.
Motor tract, diseases of, 901.
Mountain, anaemia, 44, 366; fever, 366; sickness,
366.
Mouth-breathing, 447.
Mouth, diseases of, 434; dry, 441; putrid sore, 435.
Movable kidney, 529, 664; dilatation of stomach in,
665.
Movable liver, 529, 572.
Mucous colitis, 530.
Mucous glands, affections of, 440.
Mucous patches, 268.
Muguet, 436.
Multiple gangrene, 1101.
Multiple sclerosis, 930.
Mumps, 146, 441. _
Murmur, in aneurism, 858; btain, 429; cardio-
respiratory, 331; in chlorosis, 724; in congenital
heart-disease, 846; Flint's, 800, 810; in endo-
carditis, 789; humming-top, 724; in lung cavity,
330; in subclavian artery in phthisis, 331; in
valvular disease, 800, 803, 807. 810, 812, 813.
Musca domestica, 55; M. vomitoria, 55.
Muscle callus in sterno-mastoid in infants, 1031.
Muscle-sense, 959.
Muscles, diseases of, 1111; degeneration of, in ty-
phoid fever, 70, 89.
Muscular atrophy, forms of, 907; heredity in,
906; atrophic and hypertrophic varieties, 907;
infantile form, 907; juvenile tjT)e, 907; progress-
ive neural form, 905; peroneal tjije, 905; progress-
ive central, 901, 914; hereditary influence in, 902.
Muscular contractures in hysteria, 1079.
Muscular dystrophies, 906.
Muscular exertion, coma after, 686.
Muscular exertion in heart-disease, 797, 821,
Muscular rheumatism, 396.
Musculo-spiral paralysis, 1036.
Musical murmurs, 803, 846.
Mussel poisoning, 383.
Myalgia, 396.
Myasthenia gravis, 1113.
Myasthenic reaction, 1114.
Mycosis intestinalis, 254; pulmonum, 254.
Mycotic gastritis, 459.
Myelajmia, 731.
Myelitis, acute, 944; acute diffuse, 945; acute
transverse, 946; compression, 938; in measles,
143; reflexes in, 946; transverse, of cervical
region, 947; syphilitic, 272, 273.
Myelocytes, 736.
Myelogenous leukaemia, 731.
Myiasis, 55; of nostrils and of ears, 55; of vagina,
55; cutaneous, .55; gaatro-intestinal, 55.
Myatonia, 1114.
Myiosis, 55.
Myocarditis, acute interstitial, 824; fibrous, 824;
in rheumatism, 223; segmenting, 825; in tjTjhoid
fever, 69, 78.
Myocardium, affections of, 820; lesions of, due to
disease of coronary arteries, 823.
Myoclonia, 1113.
Myoclonies, 1113.
Myoidema, 330.
Myopathies, the primary, 906.
Myosis, spinal, 889, 1014.
Myositis, 1111; dermato-, 1111; infectious, 1111;
ossificans progressiva, 1112.
Myotonia, U12; congenita, 1112.
Myotonic reaction of Erb, 1113.
Myriachit, 1055.
Mytilotoxin, 383.
Myxoedema, 768; acute, 770; congenital form, 768;
operative, 770.
Myxoma of spinal cord, 941.
Myxoneurosis intestinaUs, 530.
Naevi, multiple, of skin and mucous membranes,
595, 749.
Nagana, 7.
Nails, in typhoid fever, 75; in phthisis, 335.
Naming centre, 957.
Nasal diphtheria, 201.
Naso-pharyngeal obstruction, 447.
Neapohtan fever, 248.
Neck, cellulitis of, 444; Derbyshire neck, 764.
Necrosis, acute, of bone, 225; in typhoid fever, 88.
Necrosis in tubercle, 296.
Needle-swallowing in hysteria, 831.
Nematodes, diseases caused by, 38.
Nephralgia, 1071.
Nephrectomy, 709.
Nephritis. 686; acute, 686; after diphtheria, 204;
chronic, 692; chronic ha-morrhagic, 693; in
tonsillitis, 446; surgical treatment of, 702.
Nephritis, chronic desquamative, 692; chronic
diffuse, with exudation, 692; chronic interstitial,
694; chronic parenchymatous, 692; chronic tubal,
692; consecutive, 703; hirmorrhages in, 699; in-
creased tension in, 698; in erysipelas, 212; in ma-
laria, 16; lymphomatous, 88; relation of heart
hypertrophy to, 696; in scarlet fever, 134; in
typhoid fever, 88; suppurative, 704; syphilitic,
277; urine in, 698; vomiting in, 699.
Nephrohthia.sis, 709.
Nei>hro-phthisis (see Kidney, Tuberculosis of).
Nephroptosis, 529, 664.
Nephrorrhaphy. 666.
Nephrotomy, 709.
Nephro-typhus, 88.
Nerve-fibres, inflammation of, 998.
Nerve-root symptoms, 9.38.
"Nerve-storms," 1068.
Nerves, anastomosis of, in facial paralysis, 1022.
Nerves, diseases of peripheral, 998; diseases of
cerebral, 1005; diseases of spinal, 1033.
Nerves, lesions of anterior crural, 1038; circumflex,
1036; external popliteal, 1038; gluteal, 1038; in-
ternal popliteal, 1039; long thoracic, 1036; me-
dian, 1037; mu8culo-.spiral, 1036; obturator, 1038;
sciatic, 1038; small sciatic, 10.38; ulnar, 1037.
Nervous diarrhoea, 498, 1082.
Nervous dyspepsia, 490.
Nervous system, diseases of, 867; diffuse, 923.
Nettle rash (see Urticaria).
Neuralgia, 1068; causes of, 1069; cervico-brachial,
1070; cervico-occipital, 1033, 1070; epileptiform,
1069; influence of malaria in, 1069; intercostal,
1070; lumbar, 1071; of nerves of feet, 1071;
phrenic, 1070; plantar, 1071; post-zoster, 1070;
quinti major, 1069; red, 1102; reflex irritation in,
1069; treatment of, 1071; trigeminal, 1069;
visceral, 1071.
1132
IXDEX.
Neurasthenia, 1086: sexual, 1091; traumatic, 1096.
Neuritis, 998; arsenical, 1002 ; ascending, 1000; from
beer, 1002; fascians, 999; interstitial, 999; of in-
fants, progressive interstitial h>"pertrophic, 922;
lipomatous, 999; localized, 998, 999; parenchy-
matous, 999; multiple, 999, 1000; alcoholic, 1001;
endemic, 249, 1003; in diphtheria, 204; migra-
tory, 1000; in chronic phthisis, 334; in the infec-
tious diseases, 1002 ; in tM^hoid fever, 86 ; recurring,
1001; saturnine, 377, 1002; sj-mpathetic, 1000;
traumatic, 998; optic, 1008; from zinc, 1002.
Neurofibromatosis, generalized, 1005.
Neuroglioma, 988.
Neuromata, 1004; "amputation," 1005; plexiform,
1004.
Neurone, structure of, 867; function of, 868; degen-
eration of, 868; regeneration of, 868.
Neuro-retinitis, in anaemia, 1007.
Neuroses, occupation, 1072; traumatic, 1096.
Neutrophiles, 736.
New-born, haemorrhagic diseases of, 747.
New growths in the bowel, 521.
Night-blindness, 1008; in scurvy, 752.
Night-sweats in phthisis, 328; treatment of, 358.
Night-terrors, 449.
Ninth nerve, lesions of, 1026.
Nissl (tigroid) bodies, 868.
Nits, 53.
Nodding spasm, 1032.
Nodes, Haygarlh's, 390; Hdfcrdcn's, 391.
Nodes, symmetrical, in congenital syphilis, 271.
Nodules, rheumatic, 224.
Noma, 437; in scarlet fever, 136; in typhoid, 89,91.
Normoblasts, 722, 728.
Nose, bleeding from (see Epibtaxis), 595.
Nose, diseases of, 593.
Nummular sputa in plithisis, 323.
Nurse's contracture of Trousseau, 1074.
Nutmeg liver, 541.
Nyctalopia, 1008; in scurvy, 752.
Nylander's bismuth test in diabetes, 415.
Nystagmus, 1014; in Friedreich's ataxia, 922; in
insular sclerosis, 931; of miners, 1014.
Obesity, 431; diabetogenous, 410.
Obsession, 1054.
Obstruction of bowels, 519; acute, 522; chronic,
522.
Obturator nerve, affections of, 1038.
Occipital lobe, tumors of, 990.
Occipito-cervical neuralgia, 1033, 1070.
Occupation neuroses, 1072.
Ochronosis, 681.
Ocular palsies, treatment of, 1017.
Oculo-motor paralysis, recurring, 1013.
Odor, in small-pox, 117; in tv-phoid fever, 75.
CEdema, angio-neurotic, 1103; febrile purpuric, 744;
of glottis, 598; hereditary, 1104; of lungs, 616;
of brain, 965; malignant, of anthrax, 253; of the
brain, in ursemia, 683, 965.
Edematous laryngitis, 598.
OerteVs method in obesity, 432, 829.
(Esophageal bruit, 454; varices, 452.
CEsophagismus, 453.
CEsophagitis, acute, 451; clironic, 452; fibrinous,
452; membranous, 452.
CEsophago-malacia, 453.
CEsophago-pleuro-cutaneous fistula, 456.
CEsophagus, diseases of, 451; cancer of, 454; dila-
tations of, 456; diverticula of, 456; haemorrhage
from, in cirrhosis of liver, 559; paralysis, of, 453;
post-mortem digestion of, 455; rupture of, 455;
spasm of, 453; stricture of, 453; s>"philis of, 276;
tuberculosis of, 340; ulceration of, 452; varices of
veins, in cirrhosis of liver, 452, 559.
Oidium albicans, 436; oidiomycosis, 2.
Olfactory nerves and tracts, diseases of, 1005.
Omentope.xy in cirrhosis of the liver, 563.
Omentum, tuberculous tumor of, 311; tumor of,
in cancer of the peritonaeum, 588.
Omod>Tiia, 397.
Onomatomania, 1054.
Onycliia, in arthritis deformans, 392; in locomotor
ataxia. 892; sj-pliilitic, 268, 270.
Operation per se, effects of, in epilepsy, 1066.
Operation, tuberculosis after, 295.
Ophthalmia, gonorrhccal, with arthritis, 226.
Ophthalmoplegia, 914, 1016; externa, 1016; inter-
na, 1016.
Opisthotonos, cervical, in infants, 928; in tetanus,
260.
Opium, poisoning, diagnosis from ursemia, 686;
habit, 373; .smoking, effects of, 373.
Opjyenhcim's disease, 1114.
Opsonic index in tuberculosis, 356.
Optic nerve atropliy, 1009; hereditary, 1009;
primary, 1009; secondary, 1009; in tabes, 889.
Optic nerve and tract, diseases of, 1006.
Optic neuritis, lOOS; in abscess of brain, 994; in
brain-tumor, 989; in tuberculous meningitis, 303;
in tj-phoid fever, 87.
Oral sepsis, 440.
Orchitis, in malaria, 23; in mumps, 147; interstitial,
in sj-pbilis, 277; in t>n)lioid fever, 88; in variola,
119; parotidea, 147; tuberculous, 348; value of
in diagnosis, 348.
Ornithodorus moubata, 53; 0. Savignyi, 53; O.
megnini, 53.
Orthotonos, in tetanus, 260.
Osteitis deformans, 1 106.
Osteo-arthropathy, hypertrophic pulmonary, 1107.
Osteogenesis imperfecta, 1108.
Osteo-myelitis simulating acute rheumatism, 225.
Osteophytes in artliritis deformans, 390.
Otitis-media, in t>-phoid fever, 87; in scarlet fever,
136; in meningitis, 163; meningi tic symptoms in,
926.
Ovaries, tuberculosis of, 348.
Over-exertion, heart affections due to, 821.
Oxalate-of-lime calculus, 710.
Oxaluria, 678.
Oxygen, inhalations of, in diabetic coma, 423; in
pneumonia, 192.
Oxjniris vermicularis, 39.
Oysters, poisoning by, 383; and typhoid fever,
63.
Pachymeningitis, 923 ; cervicalis hj-pertrophica, 924;
haemorrhagica, of cerebral dura, 923; of spinal
dura, 924.
Paget' 8 disease, 1 106.
Pain, in appendicitis, 514; in cancer of stomach,
483; in pleurisy, 645; in pneumonia, 174; in ulcer
of the stomach, 474.
INDEX.
1133
Palate, paralysis of, in diphtheria, 204; in facial par-
alysis, 1020; perforation of, in scarlet fever, 136.
Palate, tuberculosis of, 339.
Palpable kidney, 664.
Palpitation of heart, 832.
Palsies, cerebral, of children, 910, 985.
Palsy, lead, 377; obstetrical, 1035; shaking, 1042.
Paludism (see Malarial Fever), 10.
Pancreas, cancer of, 579; in diabetes, 413; cysts of,
577; haemorrhage into, 573; tumors of, 579.
Pancreas, diseases of, 573; insufficiency of, 573.
Pancreatic abscess, 575; diabetes, 414; calculi, 580.
Pancreatitis, acute, 574; acute hsemorrhagic, 574;
chronic, 577; fat necrosis in, 575; gangrenous,
575; suppurative, 575.
Panophthalmitis in exophthalmic goitre, 766.
Pantophobia, 1089.
Papillitis, 1008.
Paracentesis, pericardia, 782; thoracis, 654; acci-
dents in, 654; abdominis, 592.
Paraesthesia (numbness and tingling), in neuritis,
1000; in locomotor ataxia, 891; in tumor of brain,
990; in primary combined sclerosis, 921.
Parageusis, 1026.
Paralysis, acute ascending, 918; acute spinal, of
adults, 918; acute, of infants, 914; agitans, 1042;
alcoholic, 1001; anffisthesia, 1003; asthenic bulbar,
1113; atrophic spinal, 914; Bell's, 1019; bulbar,
acute, 905; chronic, 904; of bladder, in myeUtia,
945; of brachial plexus, 1035; cerebellar, 954; in
chorea, 1049; of circumfle.x nerve, 1036; crossed or
alternate, 951, 973; " crutch," 1036; Cruveilhier's,
901; diver's, 937; of diaphragm, 1034; after
diphtheria, 204; following epilepsy, 1062; Erb's
syphilitic spinal, 913; of facial nerve, 1019; of
fifth nerve, 1017; of fourth nerve, 1014; general,
of the insane, 895; of hypoglossal nerve, 1032;
hysterical, 1078; infantile, 914; labio-glosso-
laryngeal, 904; Landry's, 918; of laryngeal ab-
ductors, 1027; of adductors, 1028; in lateral
sclerosis, 909; from lead, 377; in locomotor ataxia,
892; of long thoracic nerve, 1030; in meningitis,
303, 927; of median nerve, 1037; of musculo-
spiral nerve, 1030; obstetrical, 1035; of oculo-
motor nerves, 1013; of olfactory nerve, 1005;
periodical, 1099; in progressive muscular atrophy,
903; pseudo-bulbar, 905, 956; radial, 1036; of
rectum, in myelitis, 945; of recurrent laryngeal
nerve, 1027; secondary to visceral disease, 1000;
serratus, 1036; of sixth nerve, 1015; spinal,
family form of, 912; of third nerve, 1013; of ulnar
nerve, 1037; of vocal cords, 1027.
Paramyoclonus multiplex, 1113.
Paraphasia, 959.
Paraplegia flasque, 913.
Paraplegia, from alcohol, 1001; ataxic, 920; from
ansemia of spinal cord, 934; from compression of
cord, 938; cervical, 947; diabetic, 418; dolorosa,
940; from hsemorrhage into cord, 934; hered-
itary form of, 912; hysterical, 914, 1079; in
lathyrism, 384; from myelitis, 945; in pellagra,
384; spastic, of adults, 909; spastica cerebralis,
910; syphilitic spinal, 913; from tumor of the
cord, 942; in tabes, 892.
Parasites, diseases due to animal, 1.
Parasitic gastritis, 459.
Parasitic haemoptysis, 26.
Parasitic stomatitis, 436.
Parasyphilitic affections, 269, 895.
Para-typhoid infections, 64.
"Parchment crackling " in rickets, 427.
Parenchymatous nephritis, 692.
Paresis, general, 895.
Parieto-occipital region, brain tumors in, 990.
" Paris green," poisoning by, 379.
Parkinson's disease, 1042.
Parosmia, 1006.
Parotid bubo, 441.
Parotitis, epidemic, 146; deafness in, 148; de-
lirium in, 147; chronic, 442; orchitis in, 147
specific, 441; symptomatic, 441; after abdominal
section, 441; in pneumonia, 182; post-operative,
441; in typhoid fever, 79; in typhus fever, 108.
Paroxj'smal hsemoglobinuria, 671.
Parrot's disease, 754.
Parrot's ulcers, 436.
Parry's disease, 765.
Patellar-tendon reflex (see Knee-jerk).
Pathophobia, 1089.
Pectoriloquy, 331.
Pediculi, 53; relations of, to tache bleua,tre, 54, 75.
Pediculosis, 53.
Pediculus capitis, 53; P. corporis, 54.
Peliomata, 54, 75.
Peliosis rheumatica, 224, 744; in chorea, 1051.
Pellagra, 384.
Pelvis of kidney, affections of (see Pyelitis),
Pemphigoid purpura, 744.
Pempliigus neonatorum, 269.
Pentastomes, 52.
Peptic ulcer, 470; dyspepsia, in, 474; hajmorrhage
in, 474; jejunal, 473; pain in, 474; tenderness on
pressure in, 475.
Peptones in the urine, 674.
Perforating ulcer of foot in tabes, 892; in diabetes,
417.
Perforation of bowel, in dysentery, 0, 245; in
typhoid fever, 67, 81.
Periarteritis, gummatous, 277; nodosa, 866.
Pericardial friction, 777.
Pericardite brightique, 775.
Pericarditis, 775; acute fibrinous, 776; aphonia in,
779; chronic adhesive, 782; delirium in, 779;
dysphagia in, 779; epidemics of, 776; epilepsy in,
779; from extension of disease, 775; from foreign
body, 775; in chorea, 1050; in foetus, 776; in
gout, 405; in rheumatism, 223; haemorrhagic,
778; hyperpyrexia in, 777, 779; idiopathic, 775;
mental symptoms in, 779; primary, 775; pulsus
paradoxus in, 779; secondary, 775; tuberculous,
309; with effusion, 778; in typhoid fever, 69, 78.
Pericardium, adherent, 782; Friedreich's sign in,
783; calcified, 785.
Pericardium, diseases of, 775; tuberculosis of, 309;
air in, 785.
Perichondritis, laryngeal, in typhoid fever, 68, 84;
in tuberculosis, 600.
Perigastric adhesions, 473.
Perihepatitis, 562, 587.
Perinephric abscess, 717.
Perinephritis, chronic, 717.
Perinuclear basophilic granules, 400.
Periodical paralysis, 1099.
Periosteal cachexia, 753.
1184
INDEX.
Peripheral neuritis, 998.
Perisigmoiditis, 533.
Peristaltic unrest, 490, 1082.
Peritoneum, diseases of, 580.
Peritonaeum, fluid, in, 589, 592; cancer of, 588; new
growths in, 588.
Peritonaeum, tuberculosis of, 310; tumor forma-
tions in tuberculosis of, 311.
Peritonitis, actinomj'cotic, 2C4; acute general, 516.
580; appendicular, 516, 580; chronic. 586; chronic
hemorrhagic, 588; diffuse adhesive, 587; hysteri-
cal, 583; idiopathic, 580; in infants, 584; in
typhoid fever, 82; leukiemic, 734; local adhesive,
586; localized, 584; pelvic, 580; perforative, 580;
primary, 580; proliferative. .587; pyaemic, 581;
rheumatic, 580; secondary. 580; septic, 581; sub-
phrenic, 584; tuberculous. 310, 588.
Peritonitis, tuberculous, effects of operation on, 591.
PerityphUtis, 512.
"Perles" of Laennec, 611.
Pernicious antemia, 724.
Pernicious malaria, 15, 21.
Peroneal type of muscular atrophy, 905.
Pertussis (see Whooping-cough), 148.
Pesta magna, 112.
Pestis minor, 240.
Petechiae, 743; in epilepsy, 1062; in relapsing fever,
110; in scurvy, 752; in small-pox, 115; in typhoid
fever, 74; in typhus fever, 107.
Petechial fever, 157.
Petit mal, 10.58. 1062; in general paresis. 898.
Peyer'g patches in typhoid fever, 65; in tuberculosis,
341.
Phagocytosis in erysipelas, 211 ; in tuberculosis, 296.
Pharyngitis, 442; acute, 442; chronic, 443; sicca,
443.
Pharynx, acute infectious phlegmon of, 444;
haemorrhage into, 442; hyperspmia of, 442;
cedenia of, 442; paralysis of. 1027; spasm of,
1027; tuberculosis of, 339; ulceration of, 443.
Pharynx, diseases of, 442.
Philadelphia Hospital, relapsing fever at, in 1844,
109; statistics of cerebro-spinal fever, 161; of
delirium tremens in. 372.
Philadelphia Infirmary for Nervous Diseases,
statistics of chorea, 1045; of epilepsy, 1059.
Philadelphia, tuberculosis in city wards, 291;
yellow-fever epidemic in 1793, 233; typhus
epidemic in 1883. 100.
Philippine itch, 113.
Phlebitis of portal vein, 564.
Phlebo-sclerosis. 851.
Phlegmon, acute infectious, of pharynx, 444.
Phobias in neurasthenia, 1089.
Phosphates, alkaline, 679; earthy, 679.
Phosphatic calculi, 710.
Phosphaturia, 679.
Phosphorus poisoning, similarity of acute yellow
atrophy to, 540.
Phrenic nerve, affections of, 1034; neuralgia of,
1070.
Phthiriasis, 53.
Phthirius pubis, 54.
Phthisical frame, Hippocrates' description of, 293.
Phthisis, 312; chronic ulcerative, 317; acute
pneumonic, 313; arterio-sclerosis in, 337; basic
form of, 318; Bright's disease in, 334; of coal-
miners, 631; chronic arthritis in, 337; cough in
323; endocarditis in, 321, 333; diagnosis of, 33.5;
distribution of lesions in. 317: ery.sipela.'i in. 337;
fatal haemorrhage in, 338; fever in, 327; forms of
cavities in, 319; gastric symptoms of, 333;
haemoptysis in, 325; modes of death in, 338; modes
of onset in. 321; physical signs of, 329; pneumonia
in, 337; relation of fistula in ano to, 341; sputum
in, 323; summary of lesions in, 318; typhoid fever
in, 337; vomiting in. 333.
Phthisis, fibroid, 335, 628; florida, 315; renum, 345;
sj-philitic, 274; of stone-cutters, 631; unity of,
297; ventriculi, 401.
Physiological albuminuria, 672.
Pia mater, diseases of, 925.
Pick's disease, 783.
Picric-acid test for albumin, 674.
Pigeon-breast, in rickets, 428; in mouth-breathers,
449.
Pigmentation of skin, from arsenic, 380; in Base-
dow's disease, 767; from phthiriasis, 54; in
Addison's disease, 757 ; in chronic pulmonary
tuberculosis, 335; in melanosis, 758; in peritoneal
tuberculosis, 311; in scleroderma, 1109.
Pigmentation of viscera in pellagra, 384.
Pigs, tuberculosis in, 284.
Pin-worms, 39.
Piroplasmosis, 9.
Pitting in small-p>ox, 117; measures to prevent, 122.
Pituitary body in acromegaly, 1106; in gigantism,
1106; tumors of, 991.
Pityriasis versicolor, 335.
Placenta, tuberculosis of, 348.
Plague, 239; bubonic, 240; septicsemic, 241; pneu-
monic, 241; spots, 241.
Plantar neuralgia, 1071.
Plaques jaunes, 978.
Plasmodium malarix, 12; pra?cox, 13; vivax, 12.
Plastic bronchitis, 013.
Pleura, diseases of, 643.
Pleura, echinococcus of, 36; tuberculosis of, 308.
Pleural effusion, Baccelli's sign in, 647, 649; com-
pression of lung in, 04.5; haemorrhagic, 650;
position of heart in, 04C; pseudo-cavernous signs
in, 647; purulent, 648; serous effusion, constitu-
ents of, 645; sudden death in, 648.
Pleural membranes, calcification of, 655.
Pleurisy, acute, 643; chronic. 655; diaphragmatic,
651; dry, 655; with effusion, 643, 655; encysted,
651; fibrinous, 643; haemorrhagic, 650; interlobar,
651; in typhoid fever, 85; pain in side in, 645;
plastic, 643; pleural friction in, 647; primitive
dry, 656; pulsating, 649; purulent, 648; sero-
fibrinous, 643; tuberculous, 308, 644, 650; vaso-
motor phenomena in, 650.
Pleurodynia. 396.
Pleuro-pericardial friction, 330, 777.
Pleuro-peritoneal tuberculosis, 308.
Pleurothotonos in tetanus, 260.
Plexiform neuroma, 1004.
Plica polonica, 53.
Plumbism, 375; and gout, 398; as a cause of renal
cirrhosis, 695; paralysis in, .377.
Plymouth, epidemic of typhoid fever at, 62.
Pneumatosis, 491.
Pneumaturia, 416, 681.
Pneumococcus, 167, 644.
INDEX.
1135
Pneumogastric aurie 1060.
Pneumogastnc nerve affections of 1027; cardiac
branches of, 1029; gastric and oesophageal
branches of, 1029; laryngeal branches ot U)27,
pharyngeal branches of, 1027; pulmonary
branches of, 1029.
Pneumonia, acute croupous, 104; abscess in. 186;
acute deUrium in, 179; anaesthesia, 185; anti-
pneumococcic serum in, 191; bleeding in, 190;
caseous, 323; clinical varieties of, 182; cohtis,
croupous, in, 172, 281 ; com£lications of, 180; crisis
in 174; delayed resolution in, 185; " diagnosis from
acute pneumonic phthisis, 315; diplococcus
pneumoniae, 167; endocarditis in 171, 180: en-
gorgement of lung in, 170; epidemics of, 169;
fever of, 172; gangrene in, 187; gray hepatiza-
tion in, 170; herpes in, 179; immunity from, 169;
in diabetes, 183; in infants, 183; in influenza,
185; in old age, 183; meningitis in, 172, 181;
mortality of, 187; pericarditis in, 171, 180; pseudo-
crisis in, 174; purulent infiltration in, 170; re-
currence of, 182; red hepatization in, 170; re-
lapse in, 182; resolution of, 170; serum therapy
in, 169; thrombosis in, 181; toxamia in, 188;
trauma in, 166.
Pneumonia, apex pneumonia, 182; aspiration or
deglutition, 621; asthenic, 184; central, 183;
"cerebral," 179; cheesy, 297; chronic interstitial,
628; contusion, 166; creeping, 182; double, 182;
ether, 185; epidemic, 184; fibrinous, 164; hypo-
static, 015; in malaria, 16; interstitial, of the root,
in syphihs, 274; in typhoid fever, 84; larval, 184;
lobar, 164; massive, 182; migratory, 182; pleur-
ogenous interstitial, 628; post-operative, 185;
scrofulous. 297; secondary, 183; terminal, 183;
toxic, 184; typhoid pneumonia, 184; white, of the
fcBtus, 273.
Pneumonitis, 164.
Piieumonokoniosis, 631.
Pneumo-pericardium, 785.
Pneumo-peritonwum, 583.
Pneumorrhagia, 017.
Pneumothorax, 057; accutissimus of Unverricht,
658; after tracheotomy, 063; chronic, 660;
Hippocratic succussion in, 659; in phthi.sis, 320; '
from muscular effort, 658; recurrent, 658.
Pneumo-typhus, 69, 84.
Podagra, 397.
Pododynia, 1071.
Poikilocytosis, 722, 728.
Poisoning, by arsenic 379; by food, 380; by grain,
383; by lead, 375; by meat, 381 ; by milk-products,
382; ptomaine, 381; by sewer-gas, 363; by
vegetables, 383; shell-fish and fish, 383.
"Poker-back." 392.
Polariscope test in diabetes, 415.
Poliencephalitis, 986; superior, 1017.
Polio-myelitis, acute and subacute, in adults, 918;
anterior acute, 914; epidemics of, 915; etiology
of, 915; anterior chronica, 901, 914.
Polyadenomata, 486.
Polysemia, 732.
Polyarteritis acuta nodosa, 866.
Polycythemia, in diabetes, 416; in gastric ulcer,
475; with enlarged spleen and cyanosis, 762.
Polymyositis hajmorrhagica, 1112.
Polyneuritis, acute febrile, 1000; recurreiis, 1001.
Polyorrhomenitis, 308, 587.
Polyphagia, 414.
PolypncEa, 1116.
Polyserositis, 308, 587, 784.
Polyuria (see Diabktes Insipidus).
Polyuria, in abdominal tumors, 424; in hysteria,
424, 1078; in typhoid fever, 87.
Pons, lesions of, 952; tumors of. 991.
Popliteal nerve paralysis of. 1038.
Porencephalus, 986.
Porocephalus constrictus. 52.
Portal vein, diseases of, 542; thrombosis of, 542;
suppuration in, 564.
Post-epileptic symptoms. 1062.
Posterior cerebral, artery blocking of, 979.
Post-hemiplegic chorea, 987; epilepsy, 987, 1063;
movements, 987.
Post-mortem movements in cholera bodies, 230.
Post-pharyngeal abscess, 444.
Post-typhoid, anaemia, 76; temperature, 72.
Potato poisoning, 384.
Pott's disease, 938.
Pregnancy, and acute yellow atrophy, 538; and
chorea, 1046; and heart-disease, 814; and phthisis,
351; and typhoid fever, 92.
Presystolic murmur, 810.
Priapism in leukaemia, 734.
Prickly heat (see Urticaria).
Procession caterpillar, effects of, 56.
Professional spasms, 1072.
Prof eta's law, 266.
Progeria, 774.
Proglottis of t.-cnia, 28.
Progressive muscular atrophy, 901; neural, 905.
Progressive pernicious anaemia, 724; blood in, 727.
Prophylaxis, against cholera, 232; against scurvy',
752; against tuberculosis, .351; against ta?nia, 30;
against trichina, 44; against typhoid fever, 90;
against yellow fever, 238.
Prostate, tuberculosis of, 347.
Proteus vulgaris, in appendicitis, 512; in epidemic
jaundice, 364; in meat poisoning, 381.
Protozoa, disea.ses caused by, 1; parasitic, 1.
Prune-juice expectoration, 642.
Pruritus in diabetes, 414, 417; in llod^kin's disease,
741; in ura;mia, 684; in obstructive jaundice,
535; in gout, 405; in Graves' diseafse, 707.
Psammoma of spinal cord, 941.
Pseudo-anamia, 718.
Pseudo-apoplectic seizures in fatty heart, 828; with
slow pulse, 8.38.
Pseudo-biliary colic, 551.
Pseudo-bulbar paralysis, 905, 956.
Pseudo-cavernous .signs, 331 , 647, 652.
Pseudo-cyesis, 1079.
Pseudo-diphtheria, 196.
Pseudo-hydrophobia, 258.
Pseudo-hypertrophic muscular paralysis, 906.
Pseudo-leuka;mia, 738.
Pseudo-lipoma, supraclavicular. 770.
Pseudo-paralyisis, syphilitic, 754.
Pseudo-ptosis, 1014.
Pseudo-scl^rose en plaques, 931.
Pseudo-tabes, 120.
Pseudo-tuberculosis hominis streptothrica, 287.
Psilosis, 500.
Psittacosis, 368.
1136
INDEX.
Psoriasis, buccal, 439.
Psorospermiasis, 1 ; internal,!; cutaneous, 2.
Psychasthenia, 1091.
Psychoses, tj-phoid, 86.
Psychosis pol>"neuritica, 370.
Ptomaine poisoning, 381.
Ptosis, forms of, 1013; hysterical, 1013; in ataxia,
889; pseudo, 1014.
Ptyalism, 437, 440.
Puberty, barking cough of, 1081.
Pulex, irritans, 54; penetrans, 55.
Pulmonal-cerebral abscesses, 994.
Pulmonary (see Lungs); apoplexy, 618.
Pulmonarj- artery, sclerosis of, 851; perforation of,
860.
Pulmonary hiemorrhage. 325, 617.
Pulmonary orifice, congenital lesions of, 845;
atresia of, 845; stenosb of, 845; tuberculosis in,
337, 845.
Pulmonary osteo-arfhropathy, hypertrophic, 1107.
Pulmonary valve, insufficiency of, 813; stenosis of,
813.
Pulsating pleurisy, 649.
Pulsation, dynamic, of aorta, 860.
Pulse, alternating, 834; dicrotic, 70, 76; under in-
fluence of digitalis. 817; intermittent, 834; ir-
regular, 834; bigeminal. 834; trigeminal, 834.
Pulse, capillary (see Capillary); Corrigan, 801;
water-hammer, 801.
Pulse, slow, in tuberculous meningitis, 302; in
jaundice, 536 (see Bradyc.vrdi.\. 836).
Pulsus paradoxus, 779, 784. 834.
Pupil. Argyll Robertson. 889, 897, 1014.
Pupillary inaction, hemiopic, 1012.
Pupils, unequal, 1014; in general paresis, 897.
Purpura. 742; arthritic. 744; cachetic. 743; ful-
minans. 745; Henoch's, 745; infectious. 743;
mechanical. 744; neurotic. 743; peliosis rheuma-
tica in, 744; haemorrhagica. 745; myelopathic,
743; pemphigoid. 744; .simplex. 744; .sympto-
matic, 743; toxic. 743; urticans, 744; variolosa,
118.
Purpuric oedema, febrile. 744.
Pus in the urine. 676.
Pustule, malignant. 253.
Putrid sore mouth. 435
Pyaemia. 213; arterial. 791; idiopathic. 216; post-
typhoid. 89
Pyoemic abscess of liver. 563, 566.
Pyelitis, 703; intermittent fever in. 705; pyuria in,
676, 705; in typhoid fever, 88.
Pyelonephritis. 703.
Pylephlebitis adhesiva. 542.
Pylephlebitis, in dysentery. 245; in pyaemia. 217;
suppurative, 542. 564
Pylorus, hypertrophic stenosis of. 486; congenital
hMsertrophy of, 487; insufficiency of. 492; spasm
of, 492.
Pyonephrosis. 703.
Pyo-pneumothorax. 309. 657.
Pyo-pneumothorax subphrenicus, 472, 585, 660.
Pyorrhcea alveolaris. 439.
Pyramidal tract. 870.
Pyuria, 676; in tjiihoid fever, 88.
Quarantine against cholera, 232
Quartan ague, 17.
Quincke's disease, 1103; lumbar puncture, 1G3, 928.
998.
Quinine rash, 137, 743.
Quinsy (see Tonsillitis, Suppurative).
Quotidian ague, 17.
Rabies, 255.
Radial paralysis, 1036.
Rag-picker's disease. 254.
Railway brain, 109(3; spine, 1096.
Rainey's tubes, 1.
Rapid heart, 835.
Rashes, from drugs. 137, 743: in glanders. 262; in
measles, 142; in relapsing fever. 110; in rubella,
145; in scarlet fever, 132; in small-pox, 115, 116;
in s>T3hilis, 268. 270; in typhoid fever, 74; in
typhus fever, 107; in pyjemia. 217; in vaccination,
126; in varicella. 129.
Raspberry tongue in scarlet fever, 133.
Ray-fungus (actinomyces). 263.
Raynaud's disease. 1100; aphasia in. 1101; and
scleroderma. 1110; epilepsy in, 1101; hsemo-
globinuria in. 1101.
Reaction of degeneration. 881. 1003. 1021.
von Recklinghausen's disease. 1005
Recrudescence of fever in typhoid fever, 72.
Rectal crises in tabes. 891.
Rectum, irritable. 1082; stricture of. 276; syphilis
of. 276; tuberculosis of. 341.
Recurrent laryngeal nerve, paralysis of, 1027.
Recurring multiple neuritis, 1001.
Red softening of brain, 978.
Redux crepitus, 177.
Reflex epilepsy. 1060.
Reflexes, absence of, in transverse lesion of the cord,
9.39.
Reflexes in ascending paraly.sis, 910; in cerebral
hipmorrhage. 974; in locomotor ataxia. 889. 891;
in polio-myelitis acuta. 916; in .spo-stic paraplegia.
910; in hysterical paraplegia, 914. 1079; in
progressive muscular atrophy. 903.
Regurgitation, tricuspid, 811.
Reichrniinn's disease. 492.
Relapse in typhoid fever, 92; in scarlet fever, 136.
Relapsing fever. 109; spirillum of. 110.
Remittent fever. 20.
Renal calculus. 709.
Renal, colic. 711; epistaxis, 669; sand, 709; syphilis,
277; sclero.sis. 694.
Rendu's type of tremor, 1080.
Ren mobilis, 664.
Resolution in pneumonia. 170; delayed. 185.
Resonance, amphoric, 331, 658; tympanitic, 331
646. 658.
Respiratory .system, diseases of, 593.
Rest treatment. 1080; in aneurism. 861.
Retina, lesions of. 1006.
Retinal hyperaesthesia. 1008.
Retinitis. 1007; albuminuric. 1007; in anaemia,
1007; in malaria, 1007; leukiemic, 1007; pig-
mentosa. 1007; syphilitic. 268. 1007.
Retraction of head in meningitis. 303. 927; in otitis
media. 926; in typhoid fever. 85.
Retro-colUc spasm. 1031.
Retroperitonteum. hsemorrhage into, 114.
Retro-pharyngeal abscess, 444.
Retropulsion in paralysis agitans, 1044.
INDEX.
1137
Revaccination, 125.
Rhabditis Niellyi. 47.
Rhabdo-myoma of kidney, 714.
Rhabdonema intestinale, 51.
Rhachitic bones, 426.
Rhachitis, 426.
Rhagades, 270.
Rheumatic fever, 219; cerebral complications of,
224; endocarditis in, 223; fibrous nodules in, 224;
germ theory of, 221; heredity in, 220; hyper-
pyrexia in, 22.3; metabolic theory of, 221;
nervous theory of, 221; pericarditis in, 223;
purpura in, 224; sudden death in, 225.
Rheumatic gout (.see Arthritis Deform.'VNs).
Rheumatic nodules, 224.
Rheumatism, chronic, 394; muscular, 396; sub-
acute, 223; and tonsillitis, 445.
Rheumatoid arthritis (.see .\rthritis Df.form.\ns).
Rhinitis, fibrinous, 201; membranous, 201; syphi-
litic. 269.
Ribs, resection of, in empyema, 655.
Rice-water stools. 231.
Rickets, 420; acute, 430, 7.'')3; fiptal, 769.
Riga's disease, 150, 435.
Rigidity, early, in hemiplegia, 970; late, 974.
Rigors, in abscess of brain, 994; in abscess of liver,
505; in ague, 16; in pneumonia, 172; in pj'aemia,
217; in pyelitis, 705; in tuberculosis, 322; in
typhoid fever, 74.
Risus sardoniuus, 260.
Rock-fever, 248.
Rocky-mountain fever, 368.
Romberg's maaUcatory spasm, 1018; symptom, 890.
Root-nerve .symptoms in compression paraplegia,
938.
Roaary, rickety, 428.
Roseola (see Rosi-; Rash ofTyhhoiu), 74; epidemic,
145; syphilitic, 268.
" Ro.se cold," 594.
Ro.se rash in typhoid fever, 74.
Rotation in epilepsy, 1001.
Rotatory spasm in hysteria, 1080.
Rotheln, 145.
" Rough-on-rats," poisoning by, 379.
Round-W(»rms, 38.
Rub (see I'larrioN).
Rubella, 145.
Rubeola, 140; not ha, 145.
Rumination, 491.
Running pul.se in typhoid fever, 76.
Sable intestinal, 532.
Saccharomyces albicans, 436.
Sack's disease, 912.
Sacral plexus, lesions of, 1038.
St. Vitus's dance, 1045.
Salaam convulsions, 1056, 1080.
Saline injections, intravenous, in diabetic coma,
423; subcutaneous, in cholera, 233.
Saliva, arrest of, 441 ; .supersecretion of, 440.
Salivary glands, diseases of, 440; inflammation of,
441.
Salivation (see Pty.\lism), 437, 440; in small-pox,
117; in bulbar paralysis, 904.
Salpingitis, tuberculous, 348.
Saltatory spasm, 1055.
Sanatoria, treatment of tuberculosis in, 354.
73
Sand-flea, 55.
Sand, intestinal. 532; renal, 709.
Sapraemia, 213.
Saranac Sanitarium, 354
Sarcina, ventriculi, 468; in lung cavities, 324.
Sarcocystis Miescheri. 1; S. hominis, 1,
Sarcoma, of brain. 988; of kidney, 714; of liver.
568; of lung 641; mediastinal, 661; melanotic,
of liver 568.
Sarcoptes scabiei, 52.
Saturnine neuritis. 1002.
Saturnism-, 375.
Sausage poisoning, 381.
Scapulodynia. 397.
Scarlatina miliaris, 132.
Scarlatini^ sine eruptione, 134,
Scarlatinal nephritis, 134.
Scarlet fever, 130; anginose form, 134; atypical
form, 134; complications and sequelae, 134;
desquamation in, 134; eruption in, 132; fulminant
toxic variety, 134; haemorrhagic form, 134; in-
cubation of, 132; infectivity of, 130, 138; in-
vasion in, 132; malignant, 134; puerperal (seeSuR-
gic-vl); surgical, 131 ; and typhoid fever, 89, 138.
Schistosomum hamatobium, 27; Japonicum vel
Cattoi, 28.
Schiinlein's disease, 744.
School-made chorea, 1040.
Schott treatment in mycjcardial disease, 829,
Schultze's granule mas.ses, 333.
Schweninger cure in obesity, 432.
Sciatica, 1039.
Sciatic nerve, affections of, 1038.
Scirrhous cancer of lung, 641; of stomach, 480.
Sclerema in cholera infantum, 507.
Sclerema neonatorum, 1109.
Sclerodactylie, 1110.
Scleroderma, 1109.
Scli^ro.se en [)laques, 930.
Scleroses of the brain, 928; diffuse, 929; dissemin-
ated, 930; insular, 930; multiple, 929; miliary,
929; tuberous, 930.
Sclero.sis, cerebro-sriinal, 929; degenerative, 929;
developmental, 929; inflammatory, 929; of scurvy
752.
Sclerosis, primary, lateral, 909; posterior spinal (see
LoroMOTOR At.\xia), 88G; in chronic ergotism,
.383; primary combined, 920; in tubercles, 296;
renal, 694; to.xic combined, 922.
Sclerostoma, 4.5.
Sclerotic gastritis, 460.
Scolices of echinococcus, 34.
Scorbutus, 7.50.
Screw-worm, .55. .
Scrivener's palsy, 1072.
Scrofula, .304; alleged protective inoculation by, 306.
Scrofulous pneumonia, 297.
Scurvy, 750; infantile, 753; prophylaxis of, 752;
sclerosis, 752.
Scybala, 526.
Seasonal relations, of chorea, 1045; of malaria,
10; of pneumonia, 167; of rheumatism, 219; of
typhoid fever, 59.
Seborrhoea nigricans, 1083.
Secondary contracture in hemiplegia, 974.
Secondary deviation in eye muscle paralysis, 1015.
Secondary fever of small-pox, 116,
1138
INDEX.
Self-limitation in tuberculosis, 350.
Bemiluuar space of Traube, 647.
Semilunar valves, aortic, incompetencj- of, 796.
Senile emphysema, 638.
Sensation, painful, loss of, in syringomyelia, 943.
Sensation, retardation of, in ataxia, 891.
Sensory system, diseases of, 886.
Septicaemia, 213; cryTstogenetic, 215; general, 215;
gonorrhQeal,282;progressive,214;post-t>-phoid,89.
Septieo-pyiEmia, 216.
Serratus paralysis, 1036.
Serum disease, 205.
Seven-day fever, 109.
Sewer-gas, and tonsillitis, 445; poisoning, effects of,
363.
Sex, influence of, in heart-disease, 814.
Sexes, proportion of, affected with acute yellow
atrophy, 538; in chlorosis. 721; in chorea, 1045;
in exophthalmic goitre, 765; in general paresL*,
896; in haemophilia, 748.
Shaking palsy, 1042.
SheU-fish, poisoning by, 383.
Shingles, 900.
Ship-ffever, 105.
Shock as a cause of traumatic neuroses, 1096.
Shock, death from, in acute obstruction, 522.
Shoemaker's cramp, 1074.
Sick headache, 1066.
Sickness, sleeping. 7, 8.
Siderodromophobia, 1089.
Siderophobia, 1089.
Siderosis, 631 , 632.
Signal symptom (in cortical Ict^ions), 948, 990.
Singultus (see Hiccough).
Sinu.s thrombosis, 983; anil anaemia, 983; and
chlorosis, 724, 983; autochthonous, 9S3; second-
ary, in ear-disease, 983.
Siriasis, 385.
Sixth nerve, paralysis of, 1015.
Skin, itching of, 417, .535, 084, 699, 767.
Skoda's resonance in pleural effusion, 046; in
pneumonia, 176.
Skull, of congenital sypliilis, 270; of hydrocephalus,
997; of rickets, 429; percussion of, 995.
Sleeping sickness and trypanosomiasis, 7, 8.
Sleep-start in mitral incompetency, 806.
Slow heart, 836.
Small-pox, 112; complications of, 119; confluent
form, 117; contagiousness of, 112; discrete form,
116; eruption in, 116; ha-morrhagiC; 117; 'noculu-
tion in, 112; recurrent, 120; vaccination in, 112.
Small sciatic nerve, affections of, 1038.
Smell, affections of sense of (see Olfactory
Nerve), 1006.
Snake-virus, purpura caused by, 743.
SnuflSes, 270,
Softening of brain, 977.
Soil, influence of, in cholera, 230; in typhoid fever,
61.
Solanin poisoning, 384.
Solvent treatment of renal calculi, 713
Soor, 436.
Sordes, 79.
Sore throat, 442.
Soya bread, 422.
Spasm, congenital gastric, 487; pyloric, 492.
Spasm, lock, in writer's cramp, 1073.
Spasmodic wrjiieck, 1031.
Spasms, in ergotism, 383; in hydrophobia, 256; in
hysteria, 1077; of face, 1022; of muscles, after
facial paralysis, 1022; professional, 1072; salta-
tory, 1055.
Spastic paraplegia of adults, 909; hereditary, 912;
hysterical, 914; Erb's sj'philitic, 913; in children,
910; seeondarj', 913.
Specific infectious diseases, 57.
Specific treatment of typhoid fever, 102.
Spectra, fortification, 1067.
Speech (see Aphasia), 955.
Speech, in adenoid vegetations, 449; in bulbar
paralysis, 904; in insular sclerosis, 930; in general
paralysis, 898; in hereditary ataxia, 922; in
paralysis agitans, 1043; scanning, in insular
sclerosis, 930.
Spes phthisica, 334.
Spina bifida, involvement of cauda equina in, 940.
Spinal accessory nerve, paralysis of, 1030.
Spinal apoplexy, 936.
Spinal concussion, effects of, 1097.
Spinal cord, diffuse and focal diseases of, 931.
Spinal cord, affections of blood-vessels of, 934;
ana'Hiia of, 934; chronic lepto-meningitis of,
928; complete transverse lesions of, 932; com-
pression of, 938; congestion of, 934; embolism
and thrombosis of ves.sels of, 935; entiarteritis
of vessels of, 935; fissures in, 937; focal lesions
of, 932; haemorrhage into, 936; lepto-meningitis
of, 925; localization of functions of, 871; pachy-
meningitis of, 924; sclerosis, primary combined,
of, 920; syphilis of, 271; tuberculosis of, 342;
tumors of, 941 ; imilateral lesions of, 933.
Spinal epilep.sy, 910.
Spinal irritation, 1089.
Spinal membranes, huMnorrhage into 935; tumors
of, 941.
Spinal nerves, diseases of, 1033.
Spinal neurasthenia, 1089.
Spinal p..ralysis, atrophic, 914.
Spirals, Curschmn tin's. 611, 613.
Spirillum of relapsing fever, 1 10.
Spirochrete of Obermeier, 109; of sj'philis, 265.
Splanchnoptosis, 528.
Spleen, amyloid degeneration of, in syphilis, 276;
in tuberculosis, 321.
Spleen, diseases of, 7(50; abscess of, 7Cl ; cysts of,
701; endothelioma of 702; gummata of, 761;
infarct of, 761; tumors of, 701.
Spleen, enlargement of, in congenital syphilis,
209, 271; in malaria, 15, 17.
Spleen, e.xcision of, in leuka-mia, 738.
Spleen floating, 529, 760; pulsating, 734.
Spleen, in ague 15,23; in anthrax. 254; in cirrhosis
of liver, 559, 561 ; in I/odgkin's disease, 740; in
leukff-mia, 732, 734; in rickets, 428, 4.30; in acute
miliary tuberculosis. 299; in typhoid fever, 68,
83; in typhus, 107.
Spleen, rupture of 761; in malaria, 15; in typhoid
fever, G8.
Splenectomy, statistics of, 738, 762.
Splenic anaemia, 762.
Splenic fever, 252.
Splenization of lung, 310, 615, 622.
Splenomegaly, family or infantile forms of, 7S2;
primitive, 762; tropical, 9.
INDEX.
1139
Spondylitis deformans, 392.
Spondylose rhizovielique, 393.
Sporozoa, 1; parasitic, 1.
Spotted fever, 105, 157.
Sprue, 500.
Sputa, albuminoid, after aspiration of chest, 654:
alveolar cells in, 603; amcsba coli in, 6; anchovy
sauce, 6; in cancer of lung, 642; in influenza,
154; hsematoidin crystals in, 566; in anthracosis,
633; in asthma, 611; in bronchiectasis, 608;
in acute bronchitis, 602; in chronic bronchitis,
604; in putrid bronchitis, 605; in gangrene of
lung, 639.
Sputa, in phthisis, 323; in pneumonia, 175; in
acute pulmonary tuberculosis, 314; prune-juice,
642; uric-acid crystals in, 401.
Staphylococci, in broncho-pneumonia, 623; in
diphtheria, 196; in endocarditis, 789; in peritoni-
tis, 581; in pneumonia, 168; in pyaemia, 216; in
septicEcmia, 215; in tonsillitis, 445.
Status, epilepticus, 1061; hystericus, 1084.
Status lymphaticus, 755; sudden death in, 755.
Stellwag's sign, 766.
Stenocardia, 839.
Steno's duct, gaseous tumors of, 442.
Stenosis, of aortic orifice, 802; of mitral orifice.
808; of pulmonary orifice, 813, 845; of tricuspid
orifice, 812.
Steppage gait, 378, 380, 1002.
Stercoraceous vomiting, 522.
Stercoral ulcers in colitis, 501.
Stertor, in apoplexy, 970.
Stiff neck, 396.
Stigmata, in hysteria, 1083 ; in purpura, 744.
S nil's disease, 393.
Stitch in side in pneumonia, 1 74 ; in pleurisy, 645.
Stokes-Adams disease, 834, 837, 852.
Stolidity of face in general paresis, 898.
Stomach, atrophy of, 460; atony of, 492; chronic,
catarrh of, 4.59; erosions of, 470; foreign bodies in,
486; ha;morrhage from, 474, 487; hair tumors in,
486; hour-glass, 475; neuroses of, 490; non-cancer-
ous tumors in,486;8jq5hilis of, 276; tuberculosis of,
340; ulcer of, 470; washing out of (lavage), 465.
Stomach, cancer of, 479; acute, 485; absence of free
HCl in, 484; diagnosis from gastric ulcer and
chronic gastritis, 485; haemorrhage in, 483;
secondary, 480; vomiting in, 482.
Stomach contents, examination of, 483.
Stomach, dilatation of, 467; tetany in, 468.
Stomach, diseases of, 456.
Stomatitis, 434; acute, 434; aphthous, 434; epidemic,
367; fetid, 435; follicular, 434; gangrenous, 437;
herpetic, 436; mercurial, 437; neurotica chronica,
436; parasitic, 436; pemphigoid, 436; vesicular,
434; uraemic, 685.
Stone-cutter's phthisis, 631.
Stools, of acute yellow atrophy, 540; of cholera;
231 ; of dysentery, 5, 244; of typhoid fever, 80; in
hjematemesis, 489; of obstructive jaundice, 535.
Strabismus, 1015.
Strangulation of bowel, 519, 524.
"Strawberry" tongue in. scarlet fever, 133.
Streptococci in diphtheria, 196; in endocarditis,
788; in pneumonia, 168; in peritonitis, 581; in
pleurisy, 644; in pyaemia, 216; in scarlet fever,
131; in septicaemia, 215; in tonsillitis, 445.
Streptococcus diphtheritis, 196.
Streptococcus erysipelatos, 211.
Streptococcus pyogenes, in broncho-pneumonia,
623; in erysipelas, 211.
Streptothrix actinomyces, 263.
Stricture of bile-duct, 547.
Stricture of colon, cancerous, 521.
Stricture of intestine, 621; after dysentery, 245,
521; after tuberculous ulcer, 341;
Stricture of oesophagus, 453.
Stricture of pylorus, 486.
Strictures and tumors of the bowel, 521.
Stroke, apoplectic, 969.
Strongyloides intestinalis, 51.
Stuttering in mouth-breathers, 449.
Styrian peasants, arsenical habit in, 380.
Subclavian artery, murmur in and throbbing of, in
phthisis, 331.
Subphrenic peritonitis, 584.
Subsultus tendinum in typhoid fever, 85.
Succussion, Hippocratic, 659.
Succussion splash in dilated stomach, 469.
Sudamina, in rheumatic fever, 222; in typhoid fever,
74.
Sudoral form of typhoid fever, 75.
Sugar in the urine, 408.
Sulphocyanides in excess in saliva in rheumatism,
222.
wSun-stroke, 385; after-effects of, 386.
Supermotility of stomach, 490.
Suppression of urine, 668; obstructive, 711.
Suppurative nephritis, 704.
Suppurative pylephlebitis, 542, 564.
Suppurative tonsillitis, 446.
Suprarenal bodies, diseases of, 756; haemorrhage
into, 760; tuberculosis of, 760; tumors of, 760.
vSuprarenal extract, treatment by, 759.
Surgical kidney, 704.
Suspension in compression paraplegia, 940.
Sweating, in acute rheumatism, 222; in ague, 17;
in diabetes, 414; in phthisis, 328; in pyaemia,
217; in typhoid fever, 75; in malignant endo-
carditis, 790; profuse, in rickets, 428; unilateral;
in cervical caries, 939; unilateral, in aneurism,
860.
Sweating sickness, 367.
Swine fever, 368.
Si/denham's chorea, 1045.
Symmetrical gangrene, 1101.
Sympathetic ganglia, in Addison's disease, 757.
Sympathetic nerve fibres (see Vaso-motor).
Symptomatic parotitis, 441.
Syncope, fatal, in cardiac disease, 800, 827; in
phthisis, 338; in pleural effusion, 648; local, 1100.
Synovial rheumatism (see Gonorrhceal Rheu-
matism), 282.
Synovitis, gonorrhceal, 282.
Synovitis, symm'-Li'ical, in congenital syphilis, 271.
Syphilides, macular, 268; papular, 268; pustular,
268; squamous, 268; the late, 269.
Syphilis, 265; accidental infection, 266; acquired,
267; amyloid degeneration in, 269; bone lesions,
271 ; congenital, 269 ; and dementia paralytica, 269,
272; diagnosis, 278; early nerve lesions, 272; gum-
mata in, 267, 269; hereditary transmission, 266;
modes of infection, 266; of brain and cord, 271,
988 : of circulatory system, 276; of digestive tract.
1140
INDEX.
276; and life insurance, 2S1; of liver, 274; and
locomotor ataxia. 269, SS6; of lung. 273; and
marriage, 281; orchitis in, 277; primary stage of,
267; prophylaxis of, 278; quaternary stage of,
269; renal, 277; secondary stage of. 267; tertiary
stage of, 269; third generation, 271; of trachea
and bronchi, 273; and vaccinia, 126; visceral,
271.
Syphilis hsemorrhagica neonatorum, 270, 747.
Syphihtic arteritis. 277.
Syphilitic fever. 267.
SjT>hilitio nephritis, 277.
Syringomyeha, 943.
Tabes, diabetic, 418.
Tabes dorsalis (see Locomotor Ataxia), 886; iu
chronic ergotism, 383.
Tabes dorsalis spasmodique, 909.
Tabes mesenterica, 308.
Tabo-paralysis, 895.
Tache cergbrale, 75, 303.
Taches bleuatres, 54, 75.
Tachycardia, 766,835; neurasthenic, 1090; paroxys-
mal, 836.
Tactile fremitus, in pneumonia, 176; in pleural
effusion. 646; in pneumothorax, 658; in pulmo-
nary tuberciilosis, 329; at right apex, 329.
TEeniffi, varieties of, 28, 29, 31, 32.
Tseniasis, intestinal, 28; somatic, 31.
Tapping, in ascites, 592; in cirrhosis of the liver,
563; in pericarditis, 782.
Taste, disturbances of, 1026; tests for sense of, 1026.
Tea, neuritis caused by, 1002.
Techomyza fusca, 55.
Teeth, actinomyces in, 264; looseness of, in scurvy,
751; effects of stomatitis on. 438; erosion of, 438;
Hutchinson's. 271, 438; of infantile stomatitis, 438.
Teichopsia, 1067.
Telangiectasis, multiple, in recurring epistaxis, 595,
749.
Telegrapher's cramp. 1072.
Temperature .sense, loss of, in syringomyelia, 943;
in Morva7i's disease, 944.
Temperature, subnormal, in acute alcoholism, 369;
in acute tuberculosis, 299; in apoplexy, 970, in
heat exhaustion, 385; in malaria, 22; in pulmonary
tuberculosis, 327; in tuberculous meningitis, 303;
in urEemia, 684.
Temporal lobe, tumors of, 990.
Temporo-sphenoidal lobe, centre for hearing in,
1023.
Tender points in neuralgia, 1069; in neurasthenia,
1088.
Tender toes, in typhoid fever, 86.
Tendon-reflexes (see Reflexes).
Tendon transplantation in infantile paralysis, 912,
918; in hemiplegia 981.
Tenth nerve, lesions of, 1027.
Terminal infections, 218.
Tertian ague, 17.
Testes, tuberculosis of, 348; sj-pbilis of, 277; and
tonsils, relations between, 445; (see also Orchi-
tis).
Tetanus, 258; bacillus of, 259; cephalic, 260;
neonatorum, 258; pseudo, 260; and vaccinia, 127.
Tetany, 1074; after thyroidectomy, 1074; epidemic
or rheumatic, 1074; in dilatation of the stomach.
463, 1074; idiopathic workman's. 1074; in
myxoedema. 1074; in typhoid fever, SC.
Tetrodon, poisoning by, 383.
Therapeutic test in syphilis, 278.
Therapy, serum, in diarrhoeas of children, 510;
in exophthalmic goitre, 768; in plague. 242; in
pneumonia, 169; in scarlet fever, 140; in typhoid
fever, 102.
Thermic fever, 385; continued, 387.
Thermic sense, loss of. in syringomyelia, 943.
Third nerve, diseases of, 1013.
Third nerve, recurring paralysis of, 1013; signs of
paralysis of, 1013.
Thirst in diabetes, 414.
Thomsen's disease, 1112.
Thoracic duct, tuberculosis of, 298.
Thorax, deformity of, in mouth-breathers. 449; in
rickets, 428.
Thorax in emphysema, 636; in phthisis, 293 329.
Thorn-headed worms, 51.
Thornwaldfs disease, 450.
Thread-worm, 39.
Throbbing aorta, 864, 1090.
Thrombi in heart. 809; in pneumonia. 171.
Thrombi in veins ii^ typhoid fever, 78.
Thrombi, marantic, 983.
Thrombosis, in pneumonia, 181 ; of cerebral arteries,
977; of cerebral sinuses, 983; of cerebral veins,
983; of mesenteric vessels, 533; of portal vein, 542.
Thrush, 436.
Thymic asthma, 599, 772.
Thymus gland, diseases of, 771; abscess of, 773;
in acromegaly, 1106; atrophy of, 773; and
exophthalmic goitre, 773; tumors of. 773; per-
sistence of, 7.72; enlargement of, 772; sudden
death in, 772.
Thymus Tod, 756.
Thyroid extract, administration of, 771, 1076.
Thyroid gland, aberrant or accessory tumors of,
764; absence of. in cretins, 768; adenomata of,
764; cancer of, 764; congestion of, 763; in ex-
ophthalmic goitre, 767; in goitre, 764; lingual,
764; in myxoedema, 770; sarcoma of, 764;
tumors of, 764.
1 Thyroid gland, diseases of, 763.
I Thyroidism, 771.
I Thyroiditis, acute, 763.
I Tic convulsif. 1053.
j Tic douloureux, i069; extirpation of Gasserian
ganglion in, 1070.
Tick fever, 53, 368.
I Ticks, 52.
Tinnitus aurium, 1023.
I Tobacco, influence of, on the heart. 842.
Tongue, atrophy of. 1033; eczema of. 438; geograph-
ical, 438; in bulbar paralysis, 904; smoker's, 439;
spasm of, 1033; tuberculosis of, 339; unilateral
j . hemiatrophy of, 1033; tremor of, in general
paresis, 897; ulcer of frsenum in whooping-cough,
150.
Tonsillitis, 445; acute, 445; albuminuria in, 446;
endocarditis in, 446; in the newly married, 445.
Tonsillitis, chronic, 447; follicular, 445; lacunar, 445;
suppurative, 446; ami rheumatism, 445.
Tonsils, abscess of, 446; calculi of, 450; cheesy
masses in, 450; enlarged, 447; and testes, rela-
tions between, 445; tuberculosis of, 339.
INDEX.
1141
Tonsils, diseases of, 44.5.
Tophi, 401.
Topical diagnosis, spinal, 931; cerebral, 947.
Torticollis, 396, 1030; congenital, 1030; facial
asymmetry in, 1030; mental, 1031; spasmodic,
1031.
Toxaemia, 214; in pneumonia, 188.
Toxic gastritis, 458.
Toxines, in septicaemia, 213.
Tracheal tugging, 858.
Traction aneurism, 855.
Trance in hysteria, 1078, 1084.
Traube's semilunar space, 647.
Trauma as a factor in abscess of the liver, 563; can-
cer of the stomach, 479; in delirium tremens, 371;
in hsematuria, 669; in neurasthenia, 1096; in
cysts of pancreas, 577; in pneumonia, 166; in
tuberculosis, 295.
Trembles in cattle, 365.
Tremor, alcoholic, 370, 1045; in Graves' disease,
767; hereditary, 1045; hysterical, 1045, 1080; in
exophthalmic goitre, 767; intention, 930; lead,
378; in paralysis agitans, 1043; Rend,u's type of,
1080; senile, 1045; simple, 1044; toxic, 1045;
volitional, in insular sclerosis, 930.
Trichina spiralis, 39; distribution of, 41; statistics
of, in American hogs, 41; in Germany, 41; modes
of infection, 41.
Trichiniasis, 39; epidemics of, 42; prophylaxis of, 44.
Trichocephalus dispar, 51.
Trichomonas vaginalis, 25; T. hominis, 25.
Trichter brust, 329, 449.
Tricuspid regurgitation, 811.
Tricuspid valve, disease of, 811; insufficiency of,
811; stenosis of, 812.
Trigeminal neuralgia, 1069.
Trigeminus (see Fifth Nerve).
Trilocular heart, 844.
Trismus, neonatorum, 258; hysterical, 1079.
Troinmer's test, 415.
Trophic disorders, 1100.
Tropical dysentery, 2.
Trousseau's symptom, in tetany, 1075.
Trypanosomes, varieties of, 7. 8.
Trypanosomiasis, 7; and sleeping sickness, 8.
Tsetze fly disease, 7.
Tubal pregnancy, ruptured, simulating peritonitis,
584.
Tubercle bacilli, 285, 323.
Tubercle, diffuse infiltrated, 297; miliary, 295, 318;
changes in, 295; structure of, 295; nodular, 295.
Tubercles, miliary, in chronic phthisis, 318.
Tubercula dolorosa, 1005.
Tuberculin, 286; test, 350; treatment, 356.
Tuberculosis, acute miliary, 298; general or typhoid
form, 299; meningeal form, 301; pulmonary form,
300.
Tuberculosis, 284; bacillus of, 285, 323; changes
produced by bacillus, 295; chronic miliary, 318
of circulatory system, 349; cirrhotic, of liver, 342
conditions influencing infection, 292; congenital
287; dietetic treatment of, 356; distribution of
the tubercles in, 295; duration of pulmonary form
of, 350; hereditary transmission of, 287; in-
dividual prophylaxis in, 352; infection by meat,
292; infection by milk, 292; infection by inhala-
tion, 290; inoculation of, 289; in infants, 338; in
old age, 337; mastitis, 334; treatment, 352;
modes of death in pulmonary, 3.38; modes of in-
fection in, 287; natural or spontaneous, cure of,
352; of alimentary canal, 339; of brain and cord,
342; of Fallopian tubes, 348; of genito-urinary
system, 343; of kidneys, 345; of Hver, 341; of
lymphatic system, 304; of mammary gland, 349;
of ovaries, 348; of pericardium, 309; of peri-
tonaeum, 310; of placenta, 348; of pleura, 308;
of prostate, 347; of serous membranes, 308; of
testes, 348; of ureters and bladder, 347; of uterus.
348; of vesiculse seminales, 347; pregnancy, in-
fluence of, in, 351; prophylaxis in, 351; pseudo-
287; pulmonary, 312; and typhoid fever, 90; and
vaccinia, 126 ; and valvular disease of heart, 337.
TufnelVs treatment of aneurism, 861.
Tumors of brain, 988.
Tunnel anaemia, 44.
Twists and knots in the bowel, 520.
Tympanites, in intestinal obstruction, 522; hysteri-
cal, 1082; in peritonitis, 582; in tuberculous peri-
tonitis, 311; in typhoid fever, 80; as a cause of
sudden heart failure, 531.
Typhlitis, 512.
Typhoid fever, 57; abortive form, 90; afebrile, 74,
91; ambulatory form, 71, 91; anaemia in, 76; and
tuberculosis, 90; bacillus of, 59; carriers, 62; chills
in, 74; circulatory system in, 76; diabetes in, 90;
diarrhoea in, 79; digestive system in, 78; Ehrlich's
reaction in, 87; erysipelas in, 89; grave form of,
91; haemorrhage in, 80; haemorrhagic, 91; his-
torical note on, 57; immunity from, 59; and
influenza, 90; in the aged, 91; in children, 91;
in the foetus, 92; in pregnancy, 92; laparotomy
in, 103; liver in, 68, S3; Maidstone epidemic of,
62; meteorism in, 80; mild form, 90; modes of
conveyance of, 61; nervous system in, 69, 85;
noma in, 89, 91; osseous system in, 88; oysters
and, 63; parotitis in, 79; perforation of bowel in,
67, 81; peritonitis in, 82, 103; polyuria in, 87;
post- typhoid variations of temperature in, 72;
prognosis of, 96; prophylaxis of, 96; pyuria in,
88; relapses in, 92; renal system in, 87; respiratory
system in, 84; and scarlet fever, 89, 138; serum
therapy in, 102; skin rashes in, 74; spleen in, 83;
tender toes in, 88; tetany in, 86; and tuberculosis,
90; varieties of, 90; Widal's reaction in typhoid
fever, 94; Durham's theory of relapse in, 93.
Typhoid gangrene, 78; sspticaemia, 89.
Typhoid psychoses, 86.
Typhoid spine, 89.
Typhoid state in obstructive jaundice, 536; in acute
yellow atrophy, 539.
Typho-lumbricosis, 39.
Typho-malarial fever, so-called, 95, 20.
Typho toxin, 65.
Typhus fever, 105; complications and sequelae of,
108.
Typhus siderans, 108.
Tyrosin, 539.
Tyrotoxicon, 382.
Ulcer, cancerous, of intestine, 502; gastric, 470; of
duodenum, 470; of bowel in dysentery, 3; in
typhoid fever, 66.
Ulcer of mouth, 435 ; in the new-born, 436 ; in
nursing women, 435 ; of palate in infants, 436.
1142
INDEX.
Ulcer, perforating, of foot, in tabes, 892; in diabetes,
417.
Ulcerative endocarditis, 787.
Ulcers, Parrot's, 436.
Ulnar ner\-e. affections of, 1037.
Uncinaria Americana, 45.
Uncinariasis. 44.
Unconsciousness (see Coma).
Undulant fever, 247.
Urffimia. 683; cerebral manifestations of, 683;
coma in, 684; con^iilsions in, 684; diagnosis from
apoplexy, 685; dyspnoea in, 684; headache in,
684; in nephritis, 688, 702; latent. 668; local
palsifcs in, 684; mania in, 683; cedema of brain
in, 965 ; stomatitis in, 685 ; theories of, 683.
Urate (Uthate) of soda in gout, 399.
Urates in the urine, 677.
Urates (Uthates), amorphous, 677.
Ureter, blocking of. 668; mucous cysts of, 2; ob-
structed by calculi, 711; psorospermiasis of, 2;
tuberculosis of, 347.
Urethritis, gouty. 405.
Uric acid, calculus. 709; deposition of, 677; in gout,
398: in urine. 677; " showers," 405.
Uric-acid diathesis (see Lith.emia), 677.
Uric-acid headache, 405.
Uric-acid theory of gout, 398.
Urinary calculi, 709.
Urine, anomalies of the secretion of, 668.
Urine, density of, in acute nephritis, 688; in chronic
nephritis, 698; in diabetes, 415; in diabetes in-
sipidus, 425.
Urine, hsemoglobin in, 670.
Urine, in acute yellow atrophy of liver, 540; in
grave anEemia, 729; in diabetes insipidus, 425; in
diabetes mellitus, 415; in diphtheria, 204; in
erj'sipelas, 212; in gout, 402, 404. 405; in jaundice,
535; in melaniiria, 680; in pneumonia, 179; in
pulmonary tuberculosis, 334; in typhoid fever,
87; oxalates in, 678; pus in, 676.
Urine, quantity of, in chronic Bright's disease,
698; in diabetes insipidus, 425; in diabetes
mellitus, 415; in intestinal obstruction, 522.
Urine, retention of, in typhoid fever, 87.
Urine, suppression of. 668; treatment of, 669; in
cholera. 231; in acute nephritis, 689; in scarlet
fever, 135; in acute intestinal obstruction, 522;
obstructive suppression, 711.
Urine, tests for albumin in. 673; biliary pigment in.
535; blood in, 669; albumose in, 674; peptones in,
674.
Urobilin, increase of, in pernicious ansemia, 729.
Uro-genital tuberculosis, 343.
Urticaria, after tapping of hydatid cysts, 35; in
bronchial asthma, 610; epidemica, 56; giant form
(see Neurotic (Edema), 1104; -with purpura, 744;
in small-pox, 116; in tjTDhoid fever, 75.
Uterus, tuberculosis of, 348.
U-^-ula, oedema of, 442; infarction of, 442; necrosis
and sloughing of, 442, 745.
Vaccination, 123; law, 124; mark, 125; technique of,
127; rashes. 126; ulcers, 126; value of, 127;
against typhoid fever, 98.
Vaccine, antityphoid, 98.
Vaccine lymph, choice of, 127.
Vaccinia, 123; bacteriology of , 125; generalized, 126.
Vaccino-sj-pliilis, 126.
Vagabond's discoloration, 54, 7.58.
Valleix's points, 1088.
Valvular disease of heart, 793 ; and tuberculosis, 337.
Vaquez's disease, 762.
Varicella, 128; hemorrhagic, 129.
Varicella bullosa, 129; escharotica, 129.
VariceUae variolaformes, 129.
Varices, oesophageal, in cirrhosis of Uver, 452, 559.
Variola, 112; hemorrhagica, 115, 117, 118; vera,
115.
Variola haemorrhagica pustulosa, 118.
Variola sine eruptione, 119.
Varioloid. 115, 119.
Vaso-motor disorders, 1100.
Vaso-motor disturbances in caries, 939; in chronic
pleurisy. 656; in exophthalmic goitre, 767; in
hemicrania, 1067; in myelitis, 945; in neuralgia,
1069.
Veins, cerebral, thrombosis in, 983; cer^^cal dias-
tolic collapse of, 783; pulsation in, 333, 1049,
1090; sclerosis of, 851.
Vena cava, twist in, 645.
Vena cava, superior, perforation of, by aneurism,
856, 865.
Venereal disease, 265.
Venesection (see Bloodletting)
Venous pulse, 333, 1049, 1090.
Ventricles of brain, dilatation of (hydrocephalus),
996; puncture of, 998.
^'entricula^ hemorrhage, 968.
Verruca necrogenica, 289
Vertebre, caries of, 938; cervical, caries of. 939.
Vertebral artery, obstruction of, 979.
^'ertigo. auditory, 1024; cerebellar, 954; in arterio-
sclerosis, 852; in brain tumor, 989; gastric, 462;
labyrinthine, 1024; endemic paralytic, 1025.
Vesiculse seminales, tuberculosis of, 347.
Vestibular nerve, lesions of, 1024.
Vicarious, epistaxis, 596; hgemoptysis, 617.
Vincent's angina, 201.
Virus fixe, 257.
Visceroptosis, 528.
Vision, double, 1016.
Vitiligoidea, 535.
Vocal fremitus, 176, 637, 646; resonance, 177, 647.
Voice (see Speech).
Voice, alteration of, in mouth-breathers, 449.
Volitional tremor, 930.
Volvulus. 520, 524.
Vomica, 319; signs of, in phthisis, 331.
Vomit, black, 237; coffee-ground, 483.
Vomiting, in Addison's disease, 758; in Bright's
disease, 699; in cerebral abscess, 994; in cerebral
tumor, 989; in acute obstruction of intestines,
522; in chronic ulcerative phthisis, 333; in gall-
stone coUc, 711; in gastric cancer, 482; in gas-
tric ulcer, 474; hysterical fecal, 1082; inter-
mittent, of Lei/rfen, 1103; in chronic obstruction
of intestines, 523; in tuberculous meningitis, 302;
in migraine, 1067; in peritonitis, 582; in small-
pox, 115; nervous, 491; primary periodic, 491;
stercoraceous, 522; uremic, 685.
von Noorden's dietary in obesity, 432.
WaU-paper, poisoning by arsenic in, 379.
Warnings in apoplexy, 969
INDEX.
1143
Wart-pox, 119.
Warts, post-mortem, 289.
Washing out stomach, 465, 470.
Wassermanns reaction, 278.
Water-hammer pulse, 801.
Water, infection by, in diphtheria, 193; in cholera,
229; in typhoid fever, 61.
"Water on the brain," 301.
Weber, syndrome of, 303, 973, 991.
Weber's test in gastric hsemorrhage, 474.
Weil's disease, 364.
Werlhof's disease, 745.
Wernicke's hemiopic pupillary inaction, 1012.
Wet-pack, 139.
Whip-worm, 51.
White infarct of coronary arteries, 823.
White softening of the brain, 978.
White thrombi in heart, 809.
Whooping-cough, 148.
Winckel's disease (see Epidemic Hemoglobi-
nuria OF THE New-born), 270, 671, 747.
"Winged scapulae," 329.
Wintrich's sign, 331.
Wiring and electrolysis in aneurism, 862.
Woillez, maladie de, 614.
Wool-sorter's disease, 252, 254.
Word-blindness, 959.
Word-deafness, 959.
Wormian bones in hydrocephalus, 997.
Worms (see Parasites).
Wounds of the heart, 831.
Wrist-drop, 1037; in lead-poisoning, 377.
Writer's, cramp, 1072.
Wryneck, 1030; spasmodic, 1031.
Xanthelasma, 535.
Xanthine calculi, 710.
Xanthomata, 417, 535, 551.
Xanthopsia, 39 ; in jaundice, 536.
Xerostomia, 441.
Yellow fever, 233 ; epidemics of, 233.
Yellow softening of brain, 978.
Yellow vision, 39.
Zinc, peripheral neuritis from, 1002.
Zoomotherapy, 356.
Zona, 900.
(31)
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